The Future of Basic Science in Academic Surgery

Identifying Barriers to Success for Surgeon-Scientists

Sundeep G. Keswani, MD; Chad M. Moles, BSPH; Michael Morowitz, MD; Herbert Zeh, MD; John S. Kuo, MD, PhD; Matthew H. Levine, MD, PhD; Lily S. Cheng, MD; David J. Hackam, MD, PhD; Nita Ahuja, MD; Allan M. Goldstein, MD

Disclosures

Annals of Surgery. 2017;265(6):1053-1059. 

In This Article

Results

Blue Ridge Institute for Medical Research compiles data from NIH on funding to US medical schools and their departments (www.brimr.org). Annual NIH funding to surgery departments was compared to total NIH funding from 2006 to 2014. In 2006, 3.0% of NIH funding to the 25 top-funded institutions went to their surgery departments. This proportion decreased to just 2.3% in 2014 (Fig. 1A), a 23% linear decline (R 2 = 0.87; Fig. 1A). The absolute amount of funding to surgical departments over that period declined from $185,418,928 in 2006 to $157,808,838 in 2014. In contrast, total NIH funding increased from $6,223,850,681 to $6,882,730,545 over the same period. A similar trend was observed when surgery funding was compared to departments of medicine. Surgery departments had 9.6% of the level of funding of medicine departments in 2006, and this decreased to 7.7% in 2014 (Fig. 1B), a drop of 20%, again in a linear fashion (R 2 = 0.80).

Figure 1.

Steady decline in National Institutes of Health (NIH) funding of surgical research and in the prevalence of basic science in academic surgery. NIH award data for fiscal years 2006 to 2014 were obtained from the Blue Ridge Institute for Medical Research. Values include direct and indirect costs, but exclude research and development contracts. Values represent the top 25 US medical schools that receive the most NIH funding. Departments of Surgery funding relative to total institutional funding (A) and to Departments of Medicine (B) are shown. The number of basic science abstracts submitted to the ASC from 2011 to 2015 is shown (C), as well as the proportion of accepted basic science abstracts relative to all abstracts presented each year (D). Values are presented as percentages for (A), (B), and (D), as well as the number of abstracts in (C).

We analyzed data on the number of abstracts presented at the annual ASC from 2011 to 2015. In 2011, 832 abstracts were submitted, with 398 categorized as basic science. By comparison, 1128 total abstracts were submitted to the 2015 conference, of which 304 were basic science (Fig. 1C). Thus, despite a 36% increase in the total number of abstracts, there was a 24% drop in the basic science abstracts. We also identified a significant decline in the proportion of presented abstracts classified as basic science, with the percentage dropping from 51% in 2011 to 29% in 2015 (Fig. 1D; R 2 = 0.95). These data reveal a significant decline in the absolute number of basic science abstracts submitted and in the proportion presented at this academic surgical meeting. Although these results reflect trends only at the ASC, when combined with the Blue Ridge Institute for Medical Research data above, the evidence suggests a national decline in basic research by surgeons.

To understand the factors negatively impacting basic science in surgery, we conducted a survey of the AAS and SUS membership. Of the 2504 individuals who received the survey, 1033 (41.3%) academic surgeons responded, 6 (0.2%) opted out, 33 (1.3%) bounced back, and 1433 (57.2%) did not respond. The Northeast and Midwest had the highest reporting percentages with 303 (29%) and 289 (28%) responses, respectively. In total, 261 trainees (26%), 235 junior faculty (23%), 295 senior faculty (29%), and 227 division chiefs or department chairs (22%) completed the questionnaire (Fig. 2A). The most common specialties included acute care and trauma (23%), general (22%), oncology (21%), pediatrics (15%), and minimally invasive surgery (12%) (Fig. 2B). Of participants currently engaged in research, 45% indicated their primary research focus as clinical and 42% indicated basic science. Values are self-reported and individuals could choose >1 answer (Fig. 2C).

Figure 2.

Demographic characteristics of respondents. The career stage of respondents was classified as trainee, junior faculty (5 years or less out of training), senior faculty, or division/department chiefs (A). Values reflect absolute numbers for 1018 participants that answered the question ''What is your current academic position?'' Of note, 1033 respondents participated in this survey, but 15 individuals elected to skip this question. Faculty participants were classified based on their surgical specialty (B) and type of research performed (C). (B and C) Data shown represent reporting percentages of the 757 faculty members that participated in the survey.

Perceptions About Basic Science Research

Respondents were asked whether they believe that it is realistic for surgeons to be successful in basic science in today's environment. Only 32% of faculty answered "yes" (Fig. 3A). When the respondents were stratified by primary research focus, surgeons in basic science were more likely to hold this positive outlook as compared to clinical researchers (44% vs. 24%, P < 0.001; Fig. 3B). 5723%, P < 0.001; Fig. 3C). Analyzing only the basic science cohort, funded versus non-funded faculty responded positively in 47% versus 38%, though this did not reach statistical significance (not shown). Remarkably, analysis based on academic seniority revealed that only 35% of division/department chiefs responded that it is realistic to expect surgeons to succeed in basic research, with 29% of junior faculty responding positively.

Figure 3.

Perceptions and pressures reflect a negative outlook on the ability of surgeons to succeed in basic research. Survey participants were asked: ''Do you believe it is realistic to expect surgeons to be successful basic scientists in today's hospital environment?'' Responses were tabulated for all faculty (A), those doing basic vs. clinical research (B), and those with and without funding (C).A total of 53 editorial comments were provided by the 130 basic researchers with extramural funding who answered ''no'' to this question, and their primary reasons are shown graphically in (D). Focusing on this specific subgroup, data were analyzed from the following 3 questions: ''Do considerations around work-life balance impact your desire/commitment to pursue research?'', ''Do excessive hospital administrative duties have an impact on your ability to do research?'', and ''Do you feel pressure to be clinically productive and generate revenue, so much so that it impacts your ability to do research?'' Values represent the percentage of that subgroup responding ''yes'' (E).

We specifically analyzed responses of those with extramurally funded basic science programs, as this reflects a successful cohort of investigators. Surprisingly, of 213 faculty in this category, 113 (53%) believe it is unrealistic for a surgeon to be successful in basic research. This group provided 47 comments to explain their response, and these fell into 4 common themes (Fig. 3D). The themes include (1) insufficient time, (2) inadequate departmental support, (3) poor intrinsic desire (ie, lack of motivation), and (4) difficulty in obtaining funding. Further analysis to determine the causes of pessimism among this subgroup was performed by analyzing their responses to questions regarding extrinsic pressures often cited as major challenges to surgeon-scientists. As shown in Figure 3E, a majority of this subgroup felt that the following factors represent the major barriers to success: work-life balance, administrative responsibilities, and clinical demands.

Among respondents, 57% felt that basic science research was a priority in their department. The percentage was greatest among surgeons conducting basic science as compared to clinical research (62% vs. 53%; P < 0.05). Respondents with extramural funding were more likely to perceive basic science as a departmental priority compared to nonfunded respondents (65% vs. 47%; P < 0.001). Further stratified by academic position, 61% of division chiefs and chairs with funding responded that basic science was a priority, compared to 41% of senior leaders without funding (P < 0.005). Notably, division chiefs and department chairs (54%) were more likely to believe that the amount of basic science research carried out by their surgical department was too little compared to senior (47%; P = NS) and junior faculty (44%; P < 0.05).

Since junior faculty represents the future of academic surgery, we asked "What do you think is the number one reason junior faculty members have difficulty achieving extramural funding?" Perceptions were similar among basic and clinical researchers, with both groups identifying the funding environment as a major obstacle to success (35% for basic science vs. 32% for clinical research; P = NS). Both also cited excessive clinical demands as a major challenge, with clinical researchers pointing to this more often than their peers in basic science (47% vs. 40%; P < 0.05). Additionally, responses were stratified by academic position. Junior faculty most often cited the challenging funding environment (34%) and "excessive clinical demands or insufficient protected time" (44%).

Funding Environment

Of all faculty participating in the survey (n = 757), 47% had extramural funding (Fig. 4A). The proportion of funded faculty was greater among basic scientists (69%) than among clinical researchers (37%) (Fig. 4A). Among faculty with extramural funding (n = 352), those conducting basic science comprised a significantly greater percent (61%) than those conducting clinical research (36%, P < 0.001). Among funded faculty conducting basic research, the sources of funding included NIH (51%), other federal sources (19%), foundations (29%), surgical societies (18%), and other extramural sources (21%) (Fig. 4B). Of note, the likelihood of having extramural funding for both basic and clinical investigators increased with seniority, as shown in Figure 4C.

Figure 4.

Extramural funding among academic surgeons. Faculty were asked ''Do you currently have research funding awarded from outside your institution?'' and the results are shown for all faculty and for the clinical and basic research subgroups (A). Sources of funding for basic researchers are shown in (B). Faculty with funding are stratified by basic vs. clinical research and by career stage, showing lower funding rates among younger faculty and consistently among clinical researchers (C). Respondents were asked ''Approximately how many applications have you submitted for National Institutes of Health/federal funding in the last 3 years?'' The response is shown by the dark bars, with the number of submissions along the x axis, and represents the percentage of respondents who submitted the specified number of grants. Submission number was correlated with a respondent's funding status, shown by the light bars, which represent the proportion of individuals who are actively funded for each of the groups of grant submission numbers. The results are shown for both basic science (D) and clinical research (E).

We examined the correlation between the number of federal grant applications submitted by academic surgeons and the likelihood of achieving funding. The results are shown in Figure 4D (basic researchers) and Figure 4E (clinical investigators). The "submitted" bars on the graph represent the percentage of respondents (y axis) reporting that they submitted the indicated federal grants (x axis) over the past 3 years. The "funded" bars show the proportion of individuals in each group who are actively funded. For example, 4.2% of all basic scientists reported they had submitted >8 grants, and 85% of that cohort is funded. Among basic scientists, 81% had submitted a federal grant in the last 3 years, compared to 44% of clinical researchers (P < 0.0001; Fig. 4D). For both groups, there was a significant correlation between the number of applications submitted and the likelihood of achieving extramural funding. Only 60% of basic researchers who reported submitting only 1 federal grant over the past 3 years were funded, as compared to 92% of those who submitted 5 to 8 grants (Fig. 4D). A similar trend was observed among clinical investigators (Fig. 4E). However, the number of surgeon-scientists who submitted ≥5 grant applications over a 3-year period was small, accounting for only 17% of basic scientists (Fig. 4D) and 7% of clinical researchers (Fig. 4E).

External Pressures

Multiple external pressures influence a surgeon's likelihood of achieving a successful research career. Work-life balance, for example, was found to significantly impact their desire to pursue research (Fig. 5A). When stratified by academic position, the data show that 73% of trainees identify work-life balance as affecting their commitment to research. This was significantly higher than junior faculty (65%), senior faculty (64%), and division chiefs, and department chairs (50%; P < 0.05). Another factor impacting the ability of surgeons to conduct research is excessive administrative duties, as indicated by 62% of respondents, with a disproportionate influence on more senior surgeons (Fig. 5B). Although 74% of chiefs and chairs felt their research is adversely affected by administrative responsibilities, the numbers were significantly lower for senior faculty (60%) and junior faculty (57%; P < 0.001). Finally, the pressure to be clinically productive and generate revenue is felt by most surgeon-scientists. Of all academic faculty, 86% feel pressure either "all of the time" or "some of the time," significantly impacting their ability to do research (Fig. 5C).

Figure 5.

External pressures impact academic surgeons' desire and ability to pursue research in today's environment. Faculty respondents were asked the following questions: ''Do considerations around work-life balance impact your desire/commitment to pursue research?'' (A); ''Do excessive hospital administrative duties have an impact on your ability to do research?'' (B); and ''Do you feel pressure to be clinically productive and generate revenue, so much so that it impacts your ability to do research?'' (C). In (C), responses include ''Yes, ALL the time'', ''Yes, but only SOMEtimes'', and ''NO'', as shown in x axis. Values represent percentages responding affirmatively. Respondents were also asked whether the current National Institutes of Health (NIH) payline affects their interest in pursuing basic research (D). Options included ''Yes, funding levels are so restrictive it is not worth submitting;'' ''Yes, but NIH funding has always been competitive and so you just have to try harder''; and ''No, NIH paylines do not influence my decision to submit grants or do research.'' The graph shows basic science faculty only. (E) To determine the relationship between mentoring and research funding, participants were asked to report activities of their primary research mentor, as shown in the figure. The responses are stratified by funding status and include trainees.

When queried "Is the current NIH pay line impacting your interest in pursuing basic science research?" 43% of all faculty responded "yes," with 22% feeling that "funding levels are so restrictive that it is not worth submitting." Among the 299 basic science faculty that responded to this question, 36% answered "Yes, but NIH funding has always been competitive and so you just have to try harder" (Fig. 5D), a perception more prevalent among basic scientists than among their peers in clinical research (36% vs. 16%; P < 0.0001).

Mentorship has been suggested to play an important role for young surgeon-scientists. We analyzed whether surgeons had mentors, their role as mentors, and whether a correlation could be identified between mentorship and success. Including trainees, 47% of participants did not have a current research mentor. This was more common among clinical researchers than basic scientists (56% vs. 37%; P < 0.001). Interestingly, although having a mentor did not predict funding success (Fig. 5E), several attributes of mentoring were more often reported by funded investigators (Fig. 5E), including meeting regularly with their mentor (39% vs. 30%; P < 0.001) and having a mentor who reviewed their grant applications (42% vs. 28%; P < 0.001).

Training

Over 74% of participants reported performing research as a surgical resident because they were confident they wanted to pursue an academic career, and 54% did it to enhance fellowship opportunities. When asked to identify their primary research focus as a resident, 66% reported basic science and 39% indicated clinical research. Younger respondents were significantly less likely to have conducted basic science as a resident than more senior surgeons. Division chiefs and department chairs (76%) and senior faculty (75%), for example, were significantly more likely to have conducted basic research as a surgical resident than junior faculty (60%) or trainees (53%; P < 0.001).

When faculty were asked about their first research environment after completing training, 26% said they started their own laboratory, 34% joined an established investigator, and 32% initiated a clinical research program. Interestingly, 64% of those who started their own laboratory currently have extramural funding, significantly more than those who joined an established investigator (48%) or initiated a clinical research effort (36%; P < 0.001). Interestingly, 57% of surgeon-scientists remained in a scientific field similar to their research as trainees, and this was more pronounced among basic researchers (72%) than clinical researchers (59%; P < 0.005). To gauge the overall perception about surgical trainees pursuing basic research, we found that the majority (64%) of faculty believe "basic research among surgical trainees should be limited to a select few residents with the ambition and talent to be successful in future research activities." This response did not vary significantly among trainees (66%), junior faculty (65%), senior faculty (61%), and chiefs/chairs (68%), nor did it vary between basic (64%) and clinical (65%) investigators.

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