The Surgical Scientist Program at the University of Toronto: a model for training clinician investigators

Clin Invest Med 1997;20(4):257-9.

The much-used concepts of "bench-to-bedside" and "translational research" emphasize the importance of the 2-way path between the delivery of health care and the research that creates new knowledge with application to health care. To bridge the gap between pure biomedical research and health care delivery, a species known as the clinician investigator has developed and is recognized as an essential element in biomedical scientific research.

A clinician investigator is an individual who can function at a high level of competence in clinical care and in some area of biomedical research. This implies the completion of a full training program in clinical medicine and a training program of equal rigour in research. It also implies the ability to carry 2 separate jobs at the same time -- a formidable challenge.

The Surgical Scientist Program (SSP) at the University of Toronto is one model of how such training might be accomplished as part of a postgraduate training program in a medical specialty. It was initiated in 1984 after a review of research training in the Department of Surgery at the University of Toronto. Although our clinical training programs were formally structured and highly rated, research training was loosely organized and of variable quality.

A detailed review revealed the following problems:

• poor trainee selection;
• variable supervision;
• poor training in research methodology;
• insufficient duration of research training;
• lack of support from clinical faculty;
• absence of an overall strategy aimed at producing a specific product ratio; and
• low benefit­cost ratio.

As a result of this review, we created the SSP, a defined academic stream designed to produce individuals educated to a high level of competence in both clinical care and research.

1. Applicants were carefully selected at an early stage of their clinical training.
2. SSP trainees were required to commit to a minimum of 2 years of full-time research training and register for an MSc or PhD degree (this guaranteed the standard of the research program, and the supervisors had to be members of the graduate school).
3. Trainees had to apply for fellowship funding from external granting agencies, but their salaries were guaranteed by the department if they were accepted into the program.
4. The program was given departmental priority, status and visibility.

The SSP began with 3 trainees in 1984; these represented fewer than 10% of the residents accepted into our overall program. This percentage increased over the years, and at present about 50% of our first-year residents are registering in the SSP. In the current year, 44 surgical trainees in Toronto are committed to full-time research. Most are in basic science laboratories, but others are in degree programs in clinical epidemiology, medical education, medical ethics and health administration.

Funding of the program continues to be a major problem. Although the department guarantees SSP training salaries, it has a relatively small amount of discretionary funds available, which are used as leverage. In 1996­97, for example, about 50% of the funds come from external granting agencies, 20% from provincial resident salaries and 20% from the faculty, department and divisional funds. The support from clinicians in our department has been a very important factor in the success of our program and is reflected not only in the funds that are directly transferred from earnings pools, but also in their support of the use of Ontario Ministry of Health salaries for research trainees.

Over 90% of trainees who entered the program have completed it. Although the initial commitment in every case is 2 years, 30% of trainees over the first decade have switched to a PhD program, and in recent years 50% of our trainees will complete a PhD. The success rate in degree completion is also high, at approximately 85% for both MSc and PhD trainees. A review of the total length of research training of graduates of this program reveals that, although almost 70% of them did only 2 years of research during the SSP, over 80% had completed 3 or more years of research training before taking up their first faculty position. The mean number of years of combined clinical and research training post-MD was 9 years.

The final test of success of the program will be an evaluation of the performance of its graduates. The pipeline is so long, however, that, although 119 residents have registered in the program in the first 17 years, only 19 have completed all of their clinical and research training and embarked on their careers. Only 2 of these have gone into community practice, whereas 17 are in academic positions, half in our department.

The productivity of this group of young faculty is hard to assess because they have been in their positions, on average, less than 3 years. Fifty percent of them are spending more than 40% of their time in research, almost 70% have some time protection through salary support and start-up funds, and 50% have obtained initial competitive grant funding.