Experience with nurturing clinical investigation in Alberta
Jacques W. Magnan, PhD
Matt W. Spence, MD, PhD
Clin Invest Med 1997;20(4):275-8.
Dr. Magnan is Director and Dr. Spence is President and Chief Executive Officer of the Alberta Heritage Foundation for Medical Research, Edmonton, Alta.
Clinical investigation is concerned with understanding normal and disturbed human biology so that the mechanisms of disease can be appreciated and treatments developed. Accordingly, clinical investigators use and contribute to knowledge from all aspects of scientific investigation, together with the new knowledge they acquire from the treatment process itself. The interests of clinical investigators range from the most basic research to the most applied. As a result, clinical investigation is enabled through the support of training and of established investigators across the entire spectrum of the biomedical sciences. There is particular interest, however, on the part of academic health science centres, professional groups and funding agencies, in developing and maintaining a special cadre of clinical investigators who can directly translate the findings of basic research into patient care and community health services. Traditionally, this niche has been filled by individuals with an MD or equivalent, often with further specialty qualifications and with substantial training in and commitment to research in human biology and disease.
In Alberta, there has been a strong interest in clinical investigation since the early 1900s. The early faculty in the medical school at the University of Alberta (established in 1912) had a Flexnerian view of the importance of the scientific approach to medicine, and this was an integral part of the curriculum and of recruitment to develop the medical school. With the establishment of a second medical school in Calgary in the 1960s, a strong tradition of clinical investigation continued, and the founding dean, those who followed and many of the faculty leaders were noted clinical investigators.
With this culture, it is not surprising that, in the founding of the AHFMR in the early 1980s, there was a strong emphasis on the development of clinical investigation and clinical investigators in foundation programs.
In this paper, we outline some of the programs for the support of clinical investigation in Alberta, focusing on the record of a specific program, the AHFMR Clinical Investigator Award, for the support of clinical investigators in the earliest stages of their independent research careers.
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Support of clinical investigation in Alberta by the AHFMR
The active recruitment of young students into a research career is the basis of a successful culture of clinical investigation. The foundation has tried to encourage this through a variety of programs (Fig. 1).
Often the first exposure to research for a future clinical investigator is a summer research experience. The foundation has supported between 100 and 200 summer students each year since the early 1980s. In 1996, approximately one-half of the 200 students supported were registered in faculties of medicine as undergraduate students.
Medical students electing to interrupt their formal courses to obtain an MSc or PhD are eligible for support through the foundation's Studentship programs. Relatively few have availed themselves of this opportunity over the years, but use may increase with the planned establishment of formal MD/PhD programs at both the University of Alberta and the University of Calgary.
Some MD students may elect to continue research part-time, without registering for an MSc or PhD. In some cases, they already have these qualifications. Such students are eligible to apply for part-time Studentships and Fellowships.
While the Fellowship programs of the foundation support a few MDs each year, the principal source of support for physicians making a serious commitment to research is the Clinical Fellowship program. This program is intended for physicians who have completed the requirements of specialty training of the Royal College, or the Certificate program of the Canadian College of Family Medicine. The awards may be held at any site providing appropriate training (either inside or outside Alberta), and are tenable for a minimum of 2 and, generally, a maximum of 4 years. In special cases, particularly when the candidate is undertaking a degree program (MSc or PhD), support may be for a longer period.
The AHFMR Clinical Fellowship program is similar to the MRC Clinical Scientist Phase I program. However, it is not coupled with a future faculty appointment, nor is there a commitment to fund the trainee as an independent clinical investigator. This policy provides opportunities for talented individuals to train in Alberta institutions as an important part of the Alberta clinical investigative culture, and also provides the flexibility to seek faculty appointments elsewhere.
The Clinical Fellowship Program has been an important avenue for training of potential recruits for faculty positions in clinical investigation in Alberta. Of the 53 persons who have been supported as independent clinical investigators by AHFMR, 19 received previous training supported by the Clinical Fellowship Program.
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AHFMR Clinical Investigator Program
In 1983, the foundation initiated a program for the support of new clinical investigators whom Alberta institutions wished to recruit to Alberta, or who were completing research training in Alberta and were to be recruited into faculty positions. The intent of the award is to strengthen clinical investigation in the province by providing funding for highly qualified clinicians. These clinicians must be prepared to commit a clear majority of their time to further their research experience beyond the Fellowship level in a setting in which they benefit from the guidance of 1 or more competitively funded, established basic or clinical scientists. Candidates for the award must hold an MD or DDS, have successfully completed all of the requirements for clinical specialty recognition and be eligible to hold a full-time position in a clinical department of the sponsoring institution. Active participation in clinical teaching and patient care in the investigator's discipline is expected, and, of course, the applicant must demonstrate a keen interest in research, as evidenced by previous clinical and research training of at least 2 years' duration. The AHFMR Clinical Investigator award is for 3 years and is renewable for a further 3 years. The award provides a contribution to salary and fringe benefits, a contribution to the clinical earnings pool, partial secretarial support and a start-up grant.
It was recognized from the beginning that clinical investigators often do not have the length and breadth of research training of their PhD counterparts, so a protected environment and continued mentoring are critical for success in their early careers. As a result, the Foundation requires that all applicants for a Heritage Clinical Investigator award identify a mentor with expertise in their research area, who will be prepared to foster the career development of the applicant. In addition, the Foundation asks that the dean or designate and the chair of the department or division be prepared to act as a secondary mentor to ensure that the requirement to devote at least 75% of total time to research is facilitated by appropriate protection of time, career counselling and continued expressions of interest and support. In other words, it is felt that the beginning investigator requires a politically astute mentor, in addition to someone who can provide direct advice on his or her research activities.
The program enrolment rose to just over 30 investigators in the early 1990s, with a fall off in numbers to approximately 18 in 1996 (Fig. 2). The fall off reflects a variety of factors related to the turnover and availability of positions within Alberta clinical faculty, reductions in provincial and federal budgets in both the health and education sectors and health care restructuring and reform.
Since 1983, the Foundation has supported a total of 53 persons in the AHFMR Clinical Investigator program; 51 of these (96.2%) remain in academic medicine (Table 1). Of the cadre supported by this program, almost 90% are still in Alberta and 62% are still supported by the foundation, either as clinical investigators or through other types of independent investigator awards of the foundation.
On average, these 53 individuals have each published 13 peer-reviewed papers in the past 5 years (the range is between 3 and 49). Only 1 has not published.
Fourteen investigators continue to be supported through other awards of the Foundation, notably the Scholar and Senior Scholar awards (Table 1); another 14 are no longer supported. As noted previously, most of the 53 present and former clinical investigators continue to contribute as clinical investigators, but the protection of time afforded by the other awards of the foundation may provide some additional opportunities for investigative activity. The group that is still supported by the foundation, through other awards (Table 2), continues to publish at a much higher rate than those who are no longer supported by the foundation.
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Discussion and conclusions
In the opinion of those reviewing the individual and collective accomplishments of the cadre of individuals supported by the Foundation's Clinical Investigatorship Program since 1983, the program has been very successful in contributing to a strong base of clinical investigation in Alberta. The essential elements of the program appear to be the following: (1) the native ability and the research training of the clinical investigator; (2) the protection of time afforded by the foundation award; (3) the careful mentoring and protection of time by colleagues and superiors in the local environment (a requirement for AHFMR support); (4) a strongly supportive, active, "cutting-edge" research milieu around the investigator; (5) strong scientific and academic politically astute mentors who provide example and direction to the candidates and take a real interest in their work; and, (6) a departmental and institutional culture that values and supports clinical investigation.
The program remains a high priority for the foundation.
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Discussion
It is worth noting that the MRC Clinician Scientist Phase II program has many of the attributes of the AHFMR Clinical Investigator Program. Together, they represent funded programs specially targeted to new clinician scientists going through the precarious transition phase from trainee to independent investigator.
The feedback from the breakout discussion groups strongly supported, once again, expansion and maintaining these programs. This effort will require a partnership among departments, faculties, hospitals, research institutes and granting agencies.
