The Decline of the Surgeon Scientist
by Karen Appold • September 24, 2017
Fewer surgeons perform research today, as compared with numbers from a decade or so ago. According to the American Association of Medical Colleges, although 45% of graduating medical students aspire to work in an academic setting, only about 16% will do so. Of those who do work in academic settings, up to 38% will leave academia within 10 years.
There are many reasons for this, but lack of funding tops the list. "Funding to surgeons has been steadily decreasing," said Sundeep Keswani, MD, surgical director of basic science research at Texas Children's Hospital in Houston and a co-author of an Annals of Surgery article that identified barriers to success for surgeon scientists (Ann Surg. 2017;265:1053–1059). "The National Institutes of Health (NIH) has had a stagnant budget for the last 15 years, and surgeons have had a significant reduction in overall funding from the NIH, which has been disproportionately decreased compared with their medical colleagues," he added (see Figure 1).
Allan M. Goldstein, MD, professor of surgery at Harvard Medical School, chief of pediatric surgery at Massachusetts General Hospital, and a co-author of the Annals of Surgery article, believes that the NIH and other funding agencies may look less favorably upon surgeons because they assume that surgeons commit less time to science than non-surgeons.
Dr. Goldstein also said that obtaining a grant now requires applying much more frequently, because rejection is commonplace. "Surgeons don't seem to apply for as many grants as non-surgeons, which is problematic given the frequency of rejection," he said. "Some surgeons give up or are discouraged by low funding rates."
(click for larger image) From 2003 to 2015, the NIH lost 22% of its capacity to fund research due to budget cuts, sequestration, and inflationary losses. Reduced funding capacity resulted in fewer grants, fewer discoveries, and scientists leaving the field of research.
Source: NIH
He also believes that many surgeons lack the necessary mentorship to help them secure funding. "Surgeons can fall back on clinical work, so when getting funding is tough, it is easier to give up and simply be a surgeon," Dr. Goldstein said.
Different Skill Sets
Clinical research requires substantial and specialized training from both practice and compliance standpoints. "A lack of training and focus on the skill sets needed to carry out significant and scientifically valid research could deter surgeons from pursuing this avenue," said Kurt Amsler, PhD, associate dean of research and professor in the department of biomedical sciences at the NYIT College of Osteopathic Medicine in Old Westbury, N.Y.
Dr. Keswani said that research evolves rapidly. "By the time a resident opens their own laboratory or practice, the work they were doing earlier in their career has already changed," he said. "We have to come up with a way to make training more amenable to developing surgical scientists."
Michael S. Benninger, MD, chairman of the Head and Neck Institute at the Cleveland Clinic in Ohio, believes that another reason surgeons are performing less research is because fewer institutions are paying for the expenses involved in attending educational meetings. "It makes it more difficult for researchers to break the intellectual thought process of performing research if fewer healthcare providers are exposed to ideas," he said, adding that he gets many ideas for research endeavors at conferences.
In addition, the Physician Payments Sunshine Act of 2010 requires increased transparency of financial relationships between healthcare providers and pharmaceutical manufacturers—which can be significant funders of mid-level grants [see also "What Physicians Need to Know about the Physician Payment Sunshine Act" on enttoday.org]. "As a result, it's difficult to have a relationship with a drug company and still get federal research funding," Dr. Benninger said. "Some academic medical centers frown upon clinical, device, and drug trials if they are performed within an industry relationship."
Another deterrent, Dr. Goldstein and colleagues noted, is that younger surgeons prioritize work/life balance more than those a generation ago. "Doing both surgery and research is more time consuming than it used to be," he added. "Some younger surgeons aren't willing to sacrifice that balance in order to pursue their academic goals."
More administrative duties and clinical demands also play roles. "The amount of paperwork, whether it's for documenting patient visits, billing, or educating residents, has risen substantially," Dr. Keswani added.
In addition, Deepak Mehta, MD, director of the Pediatric Aerodigestive Center and a pediatric otolaryngologist at Texas Children's Hospital in Houston, noted that a greater emphasis on multi-disciplinary teams and coordinating care requires much more time compared to 20 years ago.
According to Dr. Amsler, reimbursement is primarily based on the number of procedures performed. "Therefore, the more surgeries that are done, the greater the hospital's income," he said. "This increases the incentive to focus on performing surgeries over other possible pursuits, including research."
With fewer surgeons performing research, Dr. Keswani said that more non-surgeons will make decisions about what happens to surgeons' patients, which is problematic. "We see things in the operating room that give us insight into knowing how to better treat our patients," he said. "But our medical colleagues or PhD researchers may not have the same interests that we have in our surgical disease processes. If someone doesn't tackle our surgical issues, it will be a detriment to the care of our surgical patients."
The lack of research in surgery means that the practice of surgery could become relatively stagnant. "This, coupled with research advances in non-surgery areas, could potentially lead to a decline in the position of surgery in the future healthcare landscape," Dr. Amsler concluded.
Karen Appold is a freelance medical writer based in Pennsylvania.
Fewer surgeons perform research today than several decades ago.
Funding to surgeons has been steadily decreasing, and rejection rates for grants are higher.
Many surgeons lack the necessary mentorship to help secure funding.
The lack of research in surgery means that the practice of surgery could become relatively stagnant.
Five Ways to Improve Surgeon Participation in Research
It's imperative that more surgeons perform research. Experts provide some suggestions on how to improve rates of participation.
Provide training early. Poor continuity of the handoff among medical students, residents, and early-stage practitioners and expected competencies is occurring, said Arlen Meyers, MD, MBA, president and CEO of the Society of Physician Entrepreneurs, CMO of Bridge Health, CMO of Cliexa, and an emeritus professor of otolaryngology, dentistry, and engineering at the University of Colorado School of Medicine and the Colorado School of Public Health. Therefore, it's important to engage medical students early on and have them understand the importance of doing research to forward the agenda. Deepak Mehta, MD, director of the Pediatric Aerodigestive Center and a pediatric otolaryngologist at Texas Children's Hospital in Houston, concurred, adding that trainees should have more involvement in research. "They should receive more preparation, so they are capable of performing research in different areas—which might trigger some students to make it their career," he said.
Set the numbers straight. Research needs to be listed as a line item on healthcare system budgets. Also, reestablish expectations for salaries for providers who desire to be clinical scientists, said Michael S. Benninger, MD, chairman of the Head and Neck Institute at the Cleveland Clinic in Ohio.
Seek out funding streams. Organizations' development officers should look for donors whose primary objective is to fund research—which currently doesn't have its own ready revenue stream. "How we direct donors is important," Dr. Benninger said. Along these lines, Dr. Mehta said that having a separate funding agency committed to surgical and translational research would be helpful. "This would support surgeons and push them to do more research," he said. Furthermore, Allan M. Goldstein, MD, professor of surgery at Harvard Medical School, chief of pediatric surgery at Massachusetts General Hospital, and surgeon-in-chief at MassGeneral Hospital for Children in Boston, said that funding agencies like The National Institutes of Health need to value surgeon scientists and formulate strategies to encourage them to participate more in research.
Shift attitudes. Dr. Goldstein said an attitude shift to value the surgeon as a scientist needs to occur at the leadership level. "The most staggering finding from our study, published in Annals of Surgery, is that 65% of division leaders across surgical specialties believe it is unrealistic for a surgeon to be a successful basic science researcher," said Sundeep Keswani, MD, surgical director of basic science research at Texas Children's Hospital in Houston. "There seems to be a sense of pessimism among surgical leaders when it comes to surgeon scientists." In addition, surgeons need to understand that pursuing research will be a challenge. "They need to be able to commit the effort required to submit grants and work hard to remain at the forefront of their field in order to contribute," Dr. Goldstein said. "Making mentorship a greater part of the profession could help to accomplish this."
Contribute to aggregate research projects. Although fewer surgeons are formally conducting research, if you're a practicing surgeon, Dr. Meyers said there are plenty of opportunities to contribute to aggregate projects. For example, for a surgical quality outcomes study you could contribute data to a bigger project to see if a certain procedure or intervention has value. "More specialty societies are engaging members to contribute their clinical data," he said. "In a sense, you are participating in large aggregate databases that are used to generate outcomes."
Hospitalists as Test Subjects
Lower funding rates.
Lack of specialized training.
Higher incentive to focus on performing surgery.
Increased financial transparency.
Higher priority on work/life balance.
More administrative duties and clinical demands.
Fewer institutions paying for educational meeting attendance.
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