August 2000 Bulletin

Clinician scientists face major obstacles

Orthopaedic researchers need protected time and financial assistance for overhead

Time and money. Those are key obstacles encountered by orthopaedic clinical scientists and, having identified the problems, the Orthopaedic Research Society (ORS) is looking for solutions.

There has been a worrisome decline in the number of orthopaedic scientists—down 9 percent between 1990 and 1996. Given the financial pressures on academic medicine, the decline is probably continuing.

"The biggest problem is the lack of research time because of the increased pressure to perform surgery and patient care," says Randy Rosier, MD, PhD, chair, department of orthopaedics Rochester University Medical Center, N.Y. "Academic medicine has less money to support research and research is getting squeezed out."

The roots of the problem go even deeper. An AAOS report last year said, "currently, we have too few well-prepared PhD and orthopaedic surgeon scientists involved in research, [and} inadequate opportunities for education in orthopaedic research." Stuart Goodman, MD, PhD, Stanford University Medical Center, says most clinicians, upon completing residency, are not prepared to go into research because of the long and focused training process to be a clinician.

Dr. Goodman and Dr. Rosier participated in the ORS workshop, "The Future of the Orthopaedic Clinical Scientist" on March 12 where most agreed that orthopaedic scientists need protected time—perhaps two days a week—and financial assistance to cover their overhead.

Douglas Jackson, MD, 1997 AAOS president, who has been a catalyst in working with ORS to find solutions to the problems involving the orthopaedic clinical scientist, says, "As a profession, we are doing a good job of educating and training orthopaedic clinicians and surgeons. We are not doing well at reducing the obstacles that are contributing to the progressive decline in our orthopaedic clinician scientists. These important individuals will continue to spearhead and be involved with basic, patient- and population-oriented, specific disease-oriented and prevention-oriented research. They will set the standards and raise the bar for the quality of our scientific meetings, courses and publications.

"We (orthopaedic surgeons as a profession) rank much lower than most of us realize in NIH and similarly competitive grants among other specialties in medicine. This is perceived by many as a reflection of the quality of research that is being done within orthopaedics. The past two years we have spent time identifying the current obstacles to potential orthopaedic clinician scientists and trying to establish a ‘cadre’ of concerned individuals, organizations and institutions to address this deficiency in our specialty with an ongoing and concerted effort.

Dr. Rosier says "leaders in orthopaedics must work out methods to make time available; they have to create mechanisms."

He and his partner, Regis O’Keefe, MD, developed a mechanism six years ago so each can have time for research. Basically, one partner devotes four months to patient care and surgery while the other devotes the four months to research. Then they switch.

"Orthopaedic surgeons who devote their time to research as opposed to a full-time practice take a [financial] hit," says Russell Warren, MD, chair, department of orthopaedics, Hospital for Special Surgery, N.Y. "A financial commitment by an institution is needed."

An orthopaedist who does research two days [a week] and patient care three days, "has the same overhead as if he or she was in practice for five days," Dr. Warren explains. "They need help with malpractice insurance and overhead."

Both Dr. Warren and Gunnar Andersson, MD, PhD, chair, department of orthopaedics, Rush Presbyterian St. Lukes Medical Center, Chicago, and others noted that clinician researchers have to realize that their income will be less than if they were in full-time practice.

The financial rewards of clinical practice as opposed to the intellectual rewards of research draw orthopaedists with strong research backgrounds into the more lucrative clinical arenas, says Dr. Goodman.

Thomas Einhorn, MD, chair, department of orthopaedic surgery, Boston University Medical Center, doesn’t believe orthopaedic scientists should consider themselves martyrs who have accepted lower earnings in the name of the scientific pursuit. Dr. Einhorn says the scientists should view themselves as privileged to be able to enjoy the stimulation of an academic career and the recognition they receive for their accomplishments.

At a follow-up meeting of the Orthopaedic Clinician Scientist Steering Committee on March 13, Joseph Buckwalter, MD, chair, department of orthopaedic surgery, University of Iowa Hospital, summarized a report on the common ingredients to successful clinician scientist programs. The report by the AAOS department of research and scientific affairs, based on input from several orthopaedic program chairs, said the key areas to support an environment that fosters good physician-scientist research atmosphere are institutional, departmental and individual. The suggestions in the report mirrored many of the comments made at the workshop and steering committee meeting such as the need for protected and consistent time for research.

Institutions must be financially sound, have funding mechanisms in place to support research, an ongoing program to search for new endowments and financial assistance to departments to fund proposals, either partially or totally, for pilot projects or for equipment. Good clinical resources, accessibility to clinical material and excellent clinical/ surgical facilities also are needed.

The department must be financially sound and have an annual budget that allocates funds for projects that could lead to long-term and/orexternally funded research, endowments and an annual budget for continuing education. The department also needs a mechanism to make up for the difference in salaries between the physician scientist and clinically oriented physician. The department should have an atmosphere that supports a research environment, which starts with at the top with the department head.

The report suggested accepting at least one resident into a "Scholars Track" and having this person spend one of his or her five years in research. Also suggested was providing clinical research opportunities to medical students and resident; and support staff for clinical scientists.

Availability of and access to role models/mentors and colleagues within and outside the training institution also is important. There is a need for rewards for a productive research program.

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