The May issue of Academic Medicine includes a perspective piece by Scott Rivkees, MD, a Professor of Pediatrics at Yale. He bemoans the state of academic pediatrics, my own field, especially the economic pressures that drive future sub-specialists into surveys, practice improvement, and chart review projects rather than hard-core science.
Let's face the truth: biomedical research has almost always been a loss-leader for an institution. Even in the best of times, with the highest indirect rates, research funding did not cover the project, lost clinical revenue for a physician PI, preliminary data generation, and the almost inevitable bridge funding necessary at one or more gaps in extramural funding. Clinical revenue was used to support the research enterprise. After all, without research new treatments will not happen. Research also provides a (generally) positive message for the institution.
During my career (20 years now since I finished fellowship - YIKES!) research funding and clinical reimbursements have both tightened. Pediatrics proves especially vulnerable to loss of clinical revenue; in some communities, as many as 70% of newborns have Medicaid (almost always the least form of payment) as their sole health coverage. If you follow the congressional budget debates, you know reimbursement will only go down in the near future for these public programs.
So physician-scientists have increased pressure to maintain extramural funding, something that becomes more difficult every day. Many must give up (in essence) clinical practice to keep laboratories going with a sufficient level of productivity. This proves problematic on two levels: first, clinical skills and viewpoints of these investigators erode. Without time with patients, these highly trained specialists become just another scientist (no insult to PhD scientists intended; the physician part is what makes my type unique). Time in the lab means medical students and residents do not see successful physician-scientist role models.
Over the past decade, more pediatric residents have entered sub-specialty fellowships. In the view of Rivkees, most will not choose to pursue hard science (basic, clinical, or translational) but will choose softer, touchy-feely projects. After all, most will become clinician-educators rather than physician-scientists, so why bother? Given the current funding climate, I am not certain I would have pursued the same course today that I did 20 years ago (and we thought things sucked then).
Rivkees suggests some ways to help the problem, including the continuously reported death of the triple-threat, academic physician. Two accompanying editorials focus more on the positive use of change. Cooper and Gitlin (both from Vanderbilt) relay their experiences with focused clinical tracks for faculty and defined visions for departments (click here). Alan Cohen, Chair of Pediatrics at University of Pennsylvania, also relates the need to embrace the positive aspects of change. His piece also addresses one of the flaws in that of Rivekees:
First, we must agree that biomedical research is more than basic science and that, as a corollary, physician–scientists may be productively engaged in basic, translational, clinical, and even educational research. All of these can and should be areas of rigorous scientific exploration that expand the value of medicine at the levels of discovery and application. If we accept this principle, then the next key goal is to align trainees with the scientific fields to which they bring both enthusiasm and skills.
The piece by Rivkees gives little credit to qualitative research. As someone whose passions are moving in that direction, I can attest that these methods are as complex and rigorous as my rodent experiments of the previous two decades. Until we bring rigorous scientific inquiry to medical practice, education, and other "soft" pursuits, "best practice" in these areas will remain opinion, not fact!
Cohen also addresses the separation of practice and science:
physician–scientists and clinicians can work effectively with each other at the intersection of research and patient care. One of those intersections is the conference room. Separate but equal research and clinical conferences occur all too often, but cross-talk in such conferences would not only enrich both clinical and research activities but would also expose trainees to the full range of role models and, just as important, to the value of collaboration. Attending rounds and resident teaching conferences provide perfect opportunities to achieve the same goals. Grand rounds, when they are truly grand, present broad-based expertise to an audience of clinicians, investigators, and trainees. A spirited discussion at the end of the talk can present some of the most convincing evidence imaginable of the intellectual relationships among faculty members with different academic interests.
We have to get out of our silos and mingle! I believe these sorts of interactions will advance translational research far more than the bureaucracy prescribed by the CTSA program.
Finally, one thought of my own: extenders. Not just physician-extenders in the clinic (nurse practitioners and physician assistants), but research-extenders for scholarship! Personnel to assist with paperwork preparation and data entry and analysis can be hired at far less cost that increasing physician faculty to provide protected time. A busy clinician may have a great idea to improve patient care, but little time or inclination to write the Internal Review Board forms and do the study. Dedicated personnel doing these tasks full-time get really really good at these annoying chores. They could substantially increase the research output of a clinical department.
The bottom line is that the past is over. We have to quit whining about the "new economies" of academic health centers and figure out ways to make them work, without compromising our missions. If we succeed, we can publish the results in Academic Medicine.
Now that would be scholarship!