Training and career development of clinician scientists
Held May 15, 1997, at The Vaughan Estate, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.
Editors
Mel Silverman, MD
Josie Chapman
Clin Invest Med 1997;20(4):245-96.
Dr. Silverman is Professor of Medicine and Director of the Institute of Medical Science and MD/PhD Program, University of Toronto, and Ms. Chapman is Administrative Assistant, Institute of Medical Science, University of Toronto, Toronto, Ont.
Correspondence to: Institute of Medical Science, 7213 Medical Sciences Bldg., 1 King's College Circle, University of Toronto, Toronto ON M5S 1A8; fax 416 971-2253; j.chapman.smith@utoronto.ca
Readers unfamiliar with the Canadian health care system may wish to refer to Appendix 1, "Training the clinician scientist: the players and their regulations."
Introduction
Over the last 50 years, the academic "heart" of North American teaching hospitals has been a core of full-time physicians who have taken on the major responsibility for teaching and research, in addition to sharing in patient care. The most successful health science teaching complexes have been those that have been able to integrate all 3 activities, usually by relying on a set of highly trained individuals who can function effectively in all 3 domains -- as "clinician scientists." Since every physician with a medical school teaching hospital appointment is expected to participate in teaching, what distinguishes clinician scientists is that, in addition to carrying out clinical duties, they are also expected to spend a substantial part of their time in biomedical research. Typically, their investigation focuses on disease mechanisms and treatment. The clinician scientist is expected to play a crucial role in translating this new knowledge to his or her patients and students -- fulfilling the "bench-to-bedside" paradigm.
With time, the demands of research have escalated to such a degree that by the mid-1990s the job description for clinician scientists involved a minimum of 50% of their time devoted to research. In fact, for clinician scientists supported by career investigatorships the figure is even higher: they are expected to have at least 75% of their time "protected" for research activities. This increased time commitment to research has been necessitated by the explosive pace of discovery of new scientific knowledge and technology and by the requirement to master this knowledge to remain competitive in seeking research funding.
Not surprisingly, it has become more and more challenging to design appropriate training models to prepare prospective clinician scientists for careers involving both independent research and clinical responsibility. In the past the most common strategy was to identify interested and talented individuals and then "tack on" several years of research fellowship after completion of clinical training. With time, it has been recognized that more formal and rigorous research training programs are required. Over the last 15 to 20 years, much time, money and effort has gone into creating such clinician scientist programs, but considerably less attention has been devoted to developing evaluative measures for analysis of the follow-up data. Consequently, there is little agreement about which training models are best.
It seemed timely, therefore, to hold an invited retreat, with broad national representation, to compare existing clinician scientist training models, including evaluation of follow-up data on the graduates of these programs. Perhaps more important, there seemed to be an urgent need not only to address the validity of the established training models but also to conduct a critical appraisal of the later stages of clinician scientist career development -- in particular, the transition from trainee to independent investigator status and subsequent progress through the ranks.
The retreat was consequently designed to review past performance and to chart a course for the future. It also provided an opportunity to recognize publicly the unique contributions made by Dr. Bernard Langer in establishing models for training Canadian clinician scientists. On this occasion we were proud to announce the establishment of a new Bernard Langer Lecture in Health Sciences at the University of Toronto. This lecture, to be presented annually, is made possible through an endowment supported by the Institute of Medical Science and the Department of Surgery, University of Toronto, as well as Novartis Pharma Canada Inc.
The retreat participants were contributors from all sectors of academic medicine, including deans of Canadian medical schools (or their designates), representatives from granting agencies (the Medical Research Council of Canada [MRC] and the Alberta Heritage Foundation for Medical Research), the Royal College of Physicians and Surgeons of Canada, the Canadian Society for Clinical Investigation, industry, selected national faculty with an interest in the training of clinician scientists, clinical scientists and clinical scientists in training. Faculty from the United States provided an additional perspective. Our intention was to have a mix of senior and junior faculty to ensure a balanced perspective for the future. (For a complete list of participants, see Appendix 2.)
The day's agenda followed a logical progression based on the various stages of clinician scientist career development, starting with training models and progressing through the early transition to independent investigator status and beyond. However, from the outset there was concern that the highest priority must be to increase Canadian funding for biomedical research. Therefore, considerable time was spent discussing how to achieve this objective, through establishment of a national strategy to coordinate advice and lobby government at both the provincial and federal levels.
We have attempted to reconstruct the proceedings in the form of a series of articles, some of which may be characterized as "position" papers and some as program descriptions. The contribution by Dr. Whiteside and colleagues resulted from a symposium and panel discussion held on May 16 at the annual Institute of Medical Science Scientific Day. Although participants at the retreat did not have the opportunity to discuss this paper or its recommendations in open forum, the opinions expressed are timely and relevant to concerns raised on May 15 in relation to gender issues and clinician scientist career development. The results of the breakout group discussions have been summarized, and recommendations are included in the appropriate sections. In the interests of publishing this material promptly, we could not circulate the material to all participants, for which we apologize. We have tried to incorporate fairly the full complement of perspectives expressed at the meeting. Unfortunately, in some instances we may have overstated certain views -- comments are therefore welcome. Ultimately, we hope that the information presented here will serve as a resource and provide a set of recommendations that, if implemented, could maximize the success and survival of the clinician scientist.
The Retreat on the Training and Career Development of Clinician Scientists was supported by the Alberta Heritage Foundation for Medical Research, the MRC, the Royal College of Physicians and Surgeons of Canada, and the Institute of Medical Science, University of Toronto.
Background
What special roles and benefits do clinician scientists bring to the "table" of academic medicine? Some perspective can be gained from the following report from one of the breakout discussion groups, submitted by Dr. Gerald Devins.
Clinician scientists clearly have the potential to contribute importantly to biomedical research in numerous ways. First and foremost, by virtue of their academic and clinical expertise, clinician scientists can and do contribute valuably as independent investigators, developing and testing hypotheses at the levels of basic science and clinical application. Clinician scientists also participate as collaborators or co-investigators with other scientists in researching biomedical phenomena. In all such ventures, the dual expertise and interests of clinician scientists may enable them to formulate research questions more comprehensively and in novel ways. Because they are trained as clinicians, they are likely to be more sensitive to and more aware of clinically relevant issues than their counterparts in the basic sciences. Conversely, because of their expertise in basic scientific inquiry, they are better able than their clinician counterparts to conceptualize clinical observations in the form of testable hypotheses and better equipped to design experimental situations to evaluate these hypotheses in a scientifically rigorous manner. In effect, their combined expertise in the domains of clinical and basic sciences assists clinician scientists in conducting integrative science, and at the same time allows them to play a role as a "vital link" between the clinical and basic science cultures.
A third important role for clinician scientists is their contribution to the evolution of institutional research culture. Because they can relate to both basic and clinical scientists, "speak both languages," and are conversant with the relevant issues on both sides, clinician scientists can be effective in raising the scientific rigour or standard of institutional research while maintaining clinical sensitivity and relevance. Participation on institutional committees and professional bodies, such as peer-review committees and editorial boards, can help to raise the standard by ensuring that relevant and appropriate criteria are applied in the evaluation of new research.
The strengths that clinician scientists bring to the academic community can be stated explicitly. But there are more intangible, subtle ways in which clinician scientists exert a positive influence on the culture and creativity within medical schools and teaching hospitals. Dr. Sweeney's short contribution addresses this issue most eloquently.
