Report from the University of Toronto Department of Medicine Ad Hoc Committee on Career Development of Clinician Scientists

Clin Invest Med 1997;20(4):265-7.

An ad hoc committee was formed to provide suggestions regarding the long-term support of individuals recruited to clinician scientist positions in academic medicine. The committee was comprised of Drs. Neil Berinstein, Greg Downey, Dan Drucker, David Hogg, Sandy Logan, Rob Rottapel and Andre Schuh and was chaired by Dr. Katherine Siminovitch. For the purposes of this report, the committee restricted its considerations to clinicians who intend to develop their career primarily in research. The committee identified 3 major areas of concern with respect to the clinician scientist paradigm. These concerns, and recommendations to address them, are described below.

Time protection

Before considering the issues, it is important to examine the present environment in which such individuals work. While the need for "guaranteed" time for research has always been recognized, this issue has become increasingly important (at least to lab-based investigators) in view of the rapid evolution of biomedical technology. It is becoming increasingly difficult to compete at the forefront of science without some level of expertise in multiple areas of science, such as genetics, immunology, biochemistry, bioinformatics, etc. Therefore, appropriate protected research time for clinician scientists is no longer just a desired objective, but an absolute necessity.

It is also important to recognize that, because of the competitive nature of modern-day research, most clinician scientists hold appointments both in a clinical department and in one or more basic science/epidemiology departments. Often their labs are based in hospitals, and thus they also have commitments to hospital-based research institutes.

In view of this situation, demands on the clinician scientist go far beyond the standard 75% commitment considered the norm for protected time and often exceed those on PhD scientists, even though both groups of investigators may be involved in very similar types of research. For both groups, time commitments include preparing grant applications, carrying out the research program, supervising trainees and participating in the teaching and administration of the basic (or clinical) research department. But for the clinician scientist, there are important additional responsibilities arising from the need to participate in the "life" of the department of medicine: these include departmental and divisional administrative meetings, grand rounds, hospital and university divisional rounds, and medical student, resident and fellow teaching. Finally, there is the time devoted to patient care, which almost invariably stretches beyond the frequent promissory note of only a "half a day per week."

Given this scenario, it is more critical than ever that mechanisms be found for the stringent protection of clinician scientist research time. Failure to protect this time will almost surely result in the loss of clinician scientists from the Canadian research enterprise.

Recommendation

We suggest that the traditional 75% research, 25% clinical formula used to describe the activities of clinician scientists be re-evaluated. For some fields, a more realistic figure might be 90% research and 10% clinical. This suggestion takes into account the fact that the "90% research" allotment includes many activities that are not part of the investigator's research program, but are administrative duties that the clinician scientist takes on as a "good citizen." As a first step in this new formulation, we suggest that the 90%, 10% formula be incorporated into the requirement for receiving a personal salary support award from a major granting agency (e.g., the MRC scholarship or scientist awards).

Personal salary support

Current situation

In most centres, the level of personal income represents a second major deterrent to choosing a career as a clinician scientist. The extent of this problem varies in different universities, but it is certainly serious and fundamental in most institutions.

While we recognize the primary role of hospital practice plans in determining clinician and clinician scientist income, in many institutions the discrepancies between the incomes of those involved mainly in clinical work and clinical teaching and the incomes of those following a clinician scientist career track are too large to be consistent with the principle that clinician scientists are of value to the academic medicine endeavour. For example, in some hospitals or institutions, clinician scientists are assigned "targets" for their clinical earnings that necessitate their involvement in clinical duties to an extent incompatible with directing a successful research program. Furthermore, in many hospital practice plans, while base incomes are determined by academic principles (e.g., seniority, academic contribution, etc.), other sources of income may be linked to provincial health care billings. Thus, despite the stated high priority of research in academic medicine, the current system, which is predicated on the provincial fee schedule, discriminates against clinician scientists and, in particular, clinician scientists in "low billing" subspecialties. While the need for incentive systems on the clinical side is perhaps understandable, the extent of these discrepancies is not, certainly in centres claiming that clinician scientists are of value to the academic endeavour.

Recommendation

The issue regarding the "value" of any individual's contribution to the academic enterprise is clearly a complex one. However, it seems inappropriate that in an academic environment, individual incomes can be primarily determined by nonacademic principles. It also seems inappropriate that the remuneration for equivalent levels of academic contribution can vary extensively between different hospitals within the same university. In this context we believe it is incumbent upon the universities to work with the university-associated hospital medical departments to establish standards for a more equitable and uniform system for the remuneration of clinician scientists within the institution as a whole. If such a system cannot be devised, clinician scientists will be increasingly forced to forego their research for clinical activities. Almost certainly very few individuals in the "low billing" subspecialties will follow the clinician scientist career track.

Monitoring

Current situation

It is universally recognized that the first 5 to 10 years are crucial in the career development of research scientists. This is especially true for clinician scientists, for whom the external demands of patient care, rounds, etc., are likely to be much more intensive than the imperative for research activities and are likely to impede the pursuit of an independent research program in its formative stage. In such situations it is important that procedures be in place to monitor the early career activities of young investigators and to mentor these professionals. Such responsibilities need to be clearly articulated and undertaken by senior staff. Otherwise, problems such as time protection, access to research space and facilities, etc., will not be recognized until the investigator's research program is already in trouble. A failure to rapidly resolve these issues and establish a successful research program in the first 5 to 10 years usually spells the end of a career in research.

Recommendation

We believe that it is important to institute both monitoring and mentoring procedures at the early stages of the career of a clinician scientist. We suggest that a small committee be constituted for each newly recruited clinician scientist and that such a committee be responsible for both mentoring the investigator and executing a monitoring function. This committee should exercise these functions for about 3 years.

To preserve quality within the clinician scientist community, and to take into account the mechanisms of their support, we believe that it is also important to develop a formal strategy for monitoring the reappointment of clinician scientists. This process, which would occur every 3 to 5 years after the initial appointment, should resemble a tenure review, involving evaluations by a credentials committee comprised of basic and clinical scientists who, with the assistance of external referee reports, assess the appointee's research track record (publications, grant support, etc.) and forward this assessment to the department chair. These data can then be used as the basis for supporting the appointee's continued time protection, financial support, etc., as well as to garner information concerning the success rate of clinician scientists and clinician scientist training programs.

Discussion

There was considerable diversity of opinion with respect to some of the recommendations in Dr. Siminovitch's position paper. Most participants felt that, rather than an absolute percentage of time for research being set, time protection should be made the responsibility of both the clinician scientist and the department chair. The clinician scientist needs to have the discipline to say "no" to activities that detract from research, such as committees, teaching, etc. The departmental chair has to support the individual in this matter.

Most agreed that, although reasonable salary equity across divisional subspecialties was desirable, in many instances salaries reflected competition in the marketplace.

Everyone agreed that there was a real need to establish close mentoring of new clinician scientists, with special attention to establishing realistic short- and intermediate-term goals and expectations. This would allow for careful evaluation and provide continuing opportunities for feedback -- a process that would benefit both the individual clinician scientists and the departments in making long-term plans. Interestingly, very similar concerns and recommendations arose in Dr. Catharine Whiteside's paper on gender issues.