Jul 13 2009
About a week ago, Tim Kreider wrote an excellent post about the differences between medical school training and scientific training. As the only other denizen of Science-Based Medicine who has experienced both worlds, that of a PhD and that of an MD, and as the one who two decades further along the path than Tim (give or take a couple of years), his musings reminded me of similar musings I’ve had over the years, as well as emphasizing yet again something I’ve said time and time again: Most physicians are not scientists. They are not trained like scientists; they are trained to apply scientific knowledge to the care of their patients. That’s what science-based medicine is, after all, applying science to the care of patients. Not dogma. Not tradition. Not knowledge of antiquity. Science.
Leave dogma, tradition, and “ancient knowledge” to practitioners of “alternative medicine.” That’s where they all belong. Whether you want to call it “alternative medicine,” “complementary and alternative medicine” (CAM), or “integrative” medicine (IM), it rarely changes and almost never abandons therapies that science finds to be no better than placebo, whereas scientific medicine is, as it should be, ever changing, ever improving. I’ll grant you that the process is often messy. There are often false starts and blind alleys, and physicians are all too often reluctant to change their practices in response to the latest scientific findings. We sometimes even joke that for some practices, it takes the supplanting of one generation of physicians with a new generation to get rid of some practices. But change does come when the science and evidence are there. Indeed, for example, in response to evidence that a bacterium, H. pylori, causes duodenal ulcers, medical practice changed in a mere decade, which is about as fast as anyone could do the science and clinical trials to show the validity of the new concept. Although CAM practitioners like to hold up the example of Barry Marshall and Robin Warren, the researchers who discovered that H. pylori causes most duodenal ulcers, as an example of how researchers with radical ideas are ostracized, but that story is largely a myth, as our very own Kim Atwood showed.
The application of science to medicine is a difficult thing. It takes basic scientists and clinicians, but the two of them exist in different worlds. Or so it often seems. That’s why some individuals seek to straddle both worlds. Tim is one such person. So am I. Unfortunately, most people don’t understand what we do very well. We wear two hats. In my case, I’m a surgeon, and I’m a scientist. In Tim’s case, he’s a scientist and a physician, but he doesn’t yet know what kind of physician he will end up being. At the risk of sounding somewhat arrogant, I believe that we, and others like us, represent an important element in bridging the gap between basic science and clinical science, in, essentially, building a more science-based medicine.
By saying that people don’t understand very well what clinician-scientists doI don’t mean that people don’t understand what it is that a doctor or a surgeon does. Everyone knows that a doctor takes care of patients and that surgeons operate on patients, after all. I also don’t mean that they don’t understand what a basic scientist does, although most of them do seem to have some sort of an odd picture of us in a lab with test tubes and brightly colored solutions bubbling in the background, the same misconception that is common about pure basic scientists. In fact, I would go so far as to say that even most doctors and most basic scientists probably don’t understand the difficulties of combining a clinical career with laboratory research, because those of us who try to do both are in a distinct minority. The vast majority of doctors do only clinical practice, and basic scientists, not having gone to medical school, will never have the responsibility of caring for patients. Even among the minority of doctors who actually do research, the majority do mainly clinical research (testing new therapies in clinical trials, for example), and that is what most people think of when they think of doctors doing research.
Combining a laboratory research career with a clinical career has always been difficult, but these days it’s become a Herculean challenge. One aspect of biomedical research not understood by most lay people is that basic scientists in academia doing research are usually expected to pay much (usually at least 50%) of their own salaries and all of their laboratory overhead through grant support, preferably from the NIH through the “gold standard” grant known as an R01. In smaller colleges, there are often faculty whose primary responsibility is to teach, but the big universities tend to require research and grant funding to support that research. If young faculty members don’t demonstrate the ability to compete for such grant support, they don’t get tenure. Usually, upon being hired fresh out of their postdoctoral fellwoship, they are given a startup package with enough support to keep their lab going for perhaps three or four years. After that, they are expected to be able to fund their own laboratories entirely through external funds. The bottom line is: If they can’t achieve that in the time allotted, they don’t get tenure, and often when they fail to get tenure they are shown the door. It’s a very Darwinian system. Yes, there are other requirements for tenure, such as peer-reviewed scientific publications of sufficient number and quality, science good enough to win the respect of peers, and evidence of teaching talent, but the bottom line is: If you can’t attract enough funding, the other stuff will hardly be considered.
Now, consider the clinician-scientist. We have to compete for grant money with the same hungry basic scientists who can spend the vast majority of their time doing research. Worse, most of the reviewers in the study sections that decide which grant applications get funded are basic scientists. Yet, a large proportion of our time is taken up caring for patients. Those of us who have not undergone formal Ph.D. training may not have adequate experience in formulating a research plan in a logical and compelling narrative that can convince a study section that (1) we have a reasonable hypothesis; (2) we have evidence to support the hypothesis; and (3) we can formulate a scientifically credible plan to study that hypothesis. And we have to do this while devoting a significant part of our time to patient care. I am fortunate enough as a clinician-scientist in that I have a position where I can spend more time in the lab and office than I do taking care of patients, but my patient care responsibilities are still something that take up a lot of time. Consequently, some basic scientists look at doctors (especially surgeons) with condescension. (“Oh, isn’t that precious! He’s trying to do serious research!”) Unfortunately, occasionally, that condescension is deserved–but it is not deserved nearly as often as some basic scientists seem to think it is.
There was a time twenty or thirty years ago when clinician-scientists could be supported by “slush” funds derived from the clinical income of the department in which they worked. This was especially true of surgery departments, which were often revenue machines. Those days are long gone, dead and buried. Academic medical centers now have to live in the same world as private hospitals from a financial standpoint, and managed care companies are not willing to pay them more, even with the increased overhead and inefficiencies that come from training medical students and residents. True, Medicare does pay academic medical centers a per-head sum for such training, but that only covers direct costs. It doesn’t cover the hidden costs that come from the infrastructure that it takes to train residents and the inefficiencies that training residents involve. For instance, most surgeons could get a lot more operations done in a week if they didn’t have to carefully and slowly take residents through them. That would mean more revenue. But we academic surgeons have made a conscious decision that we believe that training the next generation of surgeons is of the utmost importance, and we derive many rewards from it. For example, there’s nothing like seeing a trainee achieve success. It reflects back on everyone who trained him or her.
Be that as it may, between decreased reimbursement and the increased expenses involved running an academic department, there is often little or nothing left over for research after paying the bills–if the department is lucky enough and well-managed enough not to be in the hole. In fact, academic physicians are generally expected to bring in enough clinical revenue to cover their own salary and expenses. Given that the actual collection rate for what is billed may be only $0.25 to $0.40 on the dollar (or even less), for a surgeon, covering one’s own salary, one’s secretary’s salary and overhead, office overhead (yes, the University charges office rent), and other expenses can require billing for as much as $500,000 to $1 million a year–or even more. Busy clinicians can pull this off. Part-time clinicians don’t have a prayer, particularly if they have the added overhead of a laboratory. That means, to support clinician-scientists, an academic department must explicitly make the commitment to support research in a bit of an almost “communistic” endoavor. Busy clinicians in the department must buy into the vision and be willing to subsidize the development of new physician-scientists with some of the fruits of their own clinical productivity, accepting, in essence, less income than they could make otherwise in return for the benefits of belonging to an academic department and practicing at an academic medical center. That is, in essence, the compact. The other part of the compact is that physician-scientists usually end up accepting considerably less salary than they could make in private practice (or even if they were a busy academic clinician) in order to have enough protected time to do their research. This is not an inconsiderable hurdle for a new clinician-scientist to face in these days of medical students finishing with a quarter of a million dollars of student loan debt, which is why MD/PhD programs funded by the NIH are so important.
But what about grant support? That can help, but a scientist can only ask for salary support for the percentage of his time that is devoted to the research project for which grant support is being requested. Consequently, if you are 50% clinical, there is no way you can ever support your entire salary, as basic scientists can, with grants. The most you can ever hope to support is 50%. Rare clinician-scientists can support maybe 70% of their salary if they are (1) only 30% clinical and (2) good enough at getting funded to fund the 70% effort they are putting towards research. It’s worse than that, though. Most clinicians make an academic base salary, plus a salary that comes from clinical revenue generated by the department. Grant support can only ever be applied to the academic base salary. Consequently, clinicians can rarely cover more than 20-40% of their total salary with grant support. Again, even with an NIH grant, almost no clinician-scientist can cover his own overhead through clinical activity and grant support, even very successful ones. It would take several hundreds of thousands of dollars a year in government grant support, which includes around 50% or so added to the grant for institutional overhead, to have a shot at doing it. The benefits physician-scientists bring to the department are usually not financial; rather they include intellectual benefits and the prestige that an active and successful research program brings. Again, not all departments can afford such benefits in this climate of diminishing reimbursement.
Of course, as clinician-scientists, we do have one advantage over basic scientists in one area. We understand the clinical management of the disease we’re studying in an up-close and personal way that the basic scientist can never match because they don’t take care of patients. We deal with patients with the disease and watch the course of the disease every day. We know the deficiencies in present therapies and issues needing more research attention in a way that basic scientists have a very hard time matching. We make observations about the disease that basic scientists have an even harder time making. Indeed, the flip side of the condescension basic scientists all too often heap upon clinicians trying to do basic and translational research is the similar condescension far too many clinicians heap upon the way basic scientists tend to focus on molecular and cellular mechanisms rather than practical results. We want new therapies now because patients are suffering and dying now, and are often impatient with the leisurely pace (or leisurely it seems to us) at which pure science basic scientists move. This is not an insignificant factor, given the reorientation of the NIH in recent years towards research that is likely to lead to treatments sooner rather than later. Nonetheless, overall, the forces arrayed against the success of clinician-scientists are formidable indeed, and bridging the differences between the cultures of basic scientists and pure clinicians is not the least of them.
Perhaps the most formidable challenge for a clinician-scientist is finding enough “protected time” (time with little or no patient care responsibility that is “protected” for research). One of the most challenging tasks a young clinician-scientist has is to protect his research time from the inevitable intrusions of patient care. If he doesn’t, then one day he will wake up to realize that he hasn’t been in his laboratory for anything other than brief visits for over a month; that his entire schedule has been taken over by patient care demands; and that his lab is about to run out of money because he never had time to oversee the production of enough preliminary data to write a competitive grant application. Having adequate protected time is impossible unless a young faculty member’s chairman understands the need for protected time and is willing to help protect that research time. Sometimes that means laying down the law that new patients beyond a certain number will have to be seen by other surgeons. Without the chairman’s support, even the best effort to protect research time will likely fail.
I’ve seen it with colleagues and friends over the years. Driven by the unfortunate financial reality of academic surgery today, their chairmen or division chiefs, while paying lip service to the need to provide protected time for research, would demand more and more clinical revenue, which means seeing more and more patients. For a while, the clinician-scientists would try to make up for steady infiltration of their research time by patient care responsibiliteis by working more and more late nights and weekends, but eventually something had to give, and almost inevitably it would. In these cases, what almost always “gives” is the research. The clinician-scientist concludes that he is forced to give up research and–usually–become primarily a clinician. Sometimes the rare surgeon-scientist with an exceptional devotion to and talent for research will become a pure basic scientist, but they can only do that if they are so successful at publishing and applying for grants that their labs are, in essence, awash in grant money. I’ve been extraordinarily fortunate so far in that all my bosses and the institution have done their best to help me protect my research time, but I have no illusions that, were I ever to lose all my grants and show no promise of obtaining more, my current institution (or any institution) would cut me slack for very long.
In some ways, I think that surgeons trying to do research have it worst of all. In the medical specialties, it is often possible to arrange schedules so that doctors doing research only have concentrated clinical duties one or two months out of the year, with the rest of the year serving as protected time. In medicine, pediatrics, and other specialties, this is known as being “on service” and usually involves being the attending who is responsible for an inpatient service for the month. Once the month’s up, the inpatient clinical responsibilies end, leaving only however much outpatient clinical responsibility was agreed to. For busy clinicians, this can be a lot of outpatient responsibility, but for clinician-scientists, it is often designed to be only one day of clinic a week or even less.
In surgery, such huge chunks of protected time are rarely possible for several reasons (outside of V.A. or county hospitals, and even there such huge chunks of protected time are rapidly disappearing). First, surgery is personal. Patients don’t want just any surgeon operating on them. They usually want a specific surgeon that they’ve come to trust. Consequently, the clinical burden is ongoing throughout the year, leading to us trying to protect days at a time, rather than weeks or months at a time. Second, even if we could arrange our schedules the way medical doctors do, our specialties are skill- and task-oriented. We would risk the atrophy of our operative skills if we were only to operate intensively one or two months a year. (Indeed, clinical surgeons sometimes look down on surgeon-scientists as not having the same level of surgical skills they do.) Finally, surgeons have a very special relation to their patients. If a patient I operate on has a postoperative complication, I’m going to take care of it, unless for some reason I’m on vacation or out of town (and for some surgeons, even those are not always barriers to taking care of their own). It doesn’t matter if I’m on call or not, if it’s the middle of the night or not, or if it’s during the weekend or not. That’s just the nature of surgery as a specialty. Although my surgical specialty has relatively few emergencies, for other surgical specialties (for instance, GI surgery), just this aspect of surgery alone can make a productive research career extremely problematic. The bottom line is that we are expected to be just as good as surgeons who are pure clinicians while devoting only part of our time to surgery and just as good at laboratory research as basic scientists–again, while dedicating only part of our time to it, usually a lot less than basic scientists can. We rarely succeed at both to an equal degree.
I realize that basic scientists will retort that they have other responsibilities, too. They teach, sometimes a lot. They sit on committees. They have bureacratic responsibilities that take them away from their research every bit as much as surgery. Well, not quite. If a basic scientist fails to fulfill his teaching or administrative duties or doesn’t fulfill them well, no one is likely to die or to suffer a complication or additional pain. Patient care often can’t be put off, at least not for long. Unlike teaching, it can’t always be predicted or scheduled. That’s the difference. It’s possible to succeed as basic science faculty while being not so good at other responsibilities, like teaching. My own experience with several professors during graduate school bears this observation out. There were a few professors who were highly successful in their research, with many publications, international reputations, and oodles of grant money. Unfortunately, some of them were awful in the classroom. There were even more faculty who were just OK in the classroom, but–again–ran successful laboratories.
I realize that what I said may sound arrogant to some or as though I am denigrating the difficulties basic science faculty face. I assure you that it is not and I am not. Not having much experience in teaching classes, I would probably have an absolutely hellacious time at first learning to become a competent classroom teacher (as opposed to a clinical teacher, which is different) if I ever tried to be straight basic science faculty. However, it’s just the nature of the beast. You can’t afford to be bad or even mediocre as a physician, regardless of whether or not you are a scientist as well. You just can’t. If you are bad or mediocre, you have no business treating patients. You have to be at least competent as a physician or surgeon, and preferably you should be excellent. It’s also more difficult in a highly technical specialty, like surgery. Practice makes a difference in highly technical skills, unless you happen to be one of those lucky surgeons who is just naturally gifted, and, even then, practice is what turns the technically gifted surgeon into a superstar.
Maintaining one’s medical and surgical skills as a part-time physician is perhaps the most difficult challenge facing the surgeon-scientist or the clinician-scientist. The only way many of us manage it is to focus their clinical practice like a laser very tightly on one specialized area that interests us and about which we’re passionate, which is what I have done. That’s the practicality of it. The necessity for competence when you don’t get as much experience and practice as a straight clinical surgeon almost always mandates focus. Even then, it remains really difficult. As a part-time surgeon, I don’t do nearly as many cases as a full-time surgeon does, and, as long as I continue to run a lab, I never will. That is another reason by my practice has to be tightly focused if I want to do right by my patients and still have the opportunity to do research.
It cuts both ways, too, although that’s usually less of a consideration compared to the basic science faculty with significant teaching responsibilities. I’m in essence a part-time scientist as well. I can’t devote the same amount of time to writing grants, papers, supervising the lab, or even doing experiments that most basic science faculty can and do. There just isn’t time. But perhaps the biggest issue that cuts both ways is the literature. In essence, physician-scientists have twice as much scientific/medical literature to deal try to keep up with. We have to keep up with the medical literature involving our specialties and the scientific literature involving our research, and we have less time to do it, to boot. No wonder I never feel as though I’m on top of the surgical literature. No wonder every so often I get blindsided by a paper related to my research that I never noticed, probably more so than basic scinetists do. That’s why another essential practical necessity for success is to have good people working for you and good collaborators working with you. Although this is true for any researcher, for clinician-scientists it’s doubly true: One bad hire can destroy your lab’s productivity and even ultimately your lab. You need people who can work with little supervision, and you need collaborators who can help you out with the more arcane basic science that you aren’t trained in. In return, you offer your collaborators your clinical understanding of the disease process and, if you happen to be a surgeon, one of the most precious resources of all for biomedical research: access to human tissues.
Finally, perhaps the key difference between being a basic scientist and a clinician-scientist is predictability. The basic scientist, even the one who has significant teaching responsibilities that take up a big chunk of his schedule, has a much more predictable schedule. Patient care can be made somewhat predictable, but emergencies will always occur, the number and frequency of which depend upon the specific specialty. There will always be calls on weekends or in the middle of the night. Disease doesn’t respect weekends or nights. Moreover, the natural tendency is for patient care responsibilities to grow slowly and inexorably. In essence, a surgeon can be a victim of his own clinical success, and his success in the clinical realm can negatively impact success in the scientific realm. I know one surgeon who has become so popular that every time he tries to cut back his practice in order to engage in more academic purusits, there is a backlash from his referring physicians, who start calling him to ask him if he can make an exception “just this one time” for this patient or that.
The answer is always yes.
Let’s look at a few real-life scenarios that illustrate the conflict between doing bench research and taking care of patients. Scenario number one: You are in the middle of a big experiment when the E.R. calls about a patient you recently operated on, who has returned intrabdominal sepsis. It turns out that your anastomosis has broken down, and the patient needs urgent surgery to fix the problem. However, if you take off to do the surgery, your experiment will be ruined, wasting days of work and hundreds of dollars worth of reagents. The choice is really no choice at all; you must take care of the patient and trash your experiment. You could ask one of your partners to deal with the complication, but they have patients of their own to deal with. They’re all either in clinic or in the operating room, anyway. Besides, it’s your patient’s complication. You need to deal with it, because that’s how surgeons roll.
Scenario number two: You have a grant due in a few days. You thought you had planned well, having canceled your clinic for that week several months prior and told the schedulers not to schedule any operations that week, in order to allow maximal time to finish the grant. However, there is a patient that your boss tells you that you must see and take care of now. Alternatively, one of your top referring physicians is asking you to see this patient as soon as possible. One more variation: The patient is a V.I.P. that the CEO of your hospital is asking you to see.
Scenario number three (perhaps the most common scenario): Your clinical load has been slowly growing. Almost without your realizing it, you now find yourself spending less and less time in the laboratory doing experiments until you are no longer doing benchwork at all. This alone would not necessarily be a problem. After all, many senior basic science faculty find themselves no longer doing actual benchwork. (Indeed, in a lab I worked at a long time ago, we’d go out of our way to dissuade our PI from venturing into the lab.) However, over time, your patient load continues to increase and you now find yourself spending less and less time even meeting with your lab personnel. You find that you are no longer even sure of what is going on in your lab on a day-to-day basis anymore. There are a pile of manuscripts that need to be finished, but you can’t get to them because you’re always in the clinic or in the O.R.. You try to work on them at home, but your wife and children demand their fair share of your attention when you manage to make it home for a while. You’ll soon be due to try to renew your grant, something you have no idea if you’ll be able to do now. You could try to cut back on your clinic time, but that would mean that patients’ waiting time to be seen would increase. Patients with cancer would be forced to wait longer. Also, if you cut back your clinical productivity, your department would not like it, because you would no longer be supporting your salary and overhead with clinical revenue, and this doesn’t even take into account the consideration that your referring physicians will not be pleased.
These are just a few examples, but in the end the conflicts all come down to the tension between two worlds which are very different, the world of the scientist and the world of the clinician. The world of the scientist values inquisitiveness and intellectually stimulation. It also tends to be less interested in practicality and more interested in intellectual pursuits and scientific novelty; i.e., answering questions that have never been asked or answered before. In constrast, the world of the clinician is almost purely practical. It tends to be task- and action-oriented, and protocol-driven. Asking and answering questions are valued, but only insofar as the questions and answers pertain to diagnosing and treating disease or overcoming problems that get in the way of good patient care. The clinician-scientist tries to bridge the gap between these two world in an increasingly difficult environment.
I hope I didn’t scare Tim off; so I’ll try to finish on a note of hope. Why do I continue to do it? I’ve often joked that, as an MD and a PhD, I catch equal crap from both worlds. Clinicians wonder if I know what I’m doing in the operating room, and basic scientists don’t think I can hack it as a basic scientist. So why put up with the stress of wearing two hats? Why not pick one or the other? There are two reasons. First, I think that clinician-scientists bring a unique perspective to the study of human disease that neither a clinician or a scientist alone can. Second, as I suspect must be the case with Tim, I want to make a difference. Nothing would be as satisfying as making a clinical observation, taking it to the laboratory, developing a treatment based on my laboratory observations, and then testing that in patients and seeing it work. True, I may never manage shepherd a treatment through all those stages (clinical observation, laboratory observations on the basic science, development of a therapy based on the science, and testing in clinical trials). After all, it can take a decade or more to do so, and I probably don’t have more than maybe two decades left in my career, but wouldn’t it be great if, before it’s time for me to retire, I manage to pull it off?
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