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

Discussion

Over the past several decades, federal funding to surgeon-scientists has been lagging,[3–6] and our analysis suggests that this trend continues. Compounded by the current funding environment and its impact on research productivity, the future of basic research in academic surgery may be threatened. As the cost associated with conducting basic research continues to grow, the competition to obtain funding from the NIH and other extramural sources has become progressively difficult. This is especially true when considering the steady decline in the NIH payline since 2003.[7,8] The federal budget sequestration in 2013 had a significant impact on the NIH and other agencies funding biomedical research, requiring the NIH to cut its budget by 5% ($1.6 billion) in 2013. NIH Director Francis Collins stated, "I worry desperately this means we will lose a generation of young scientists."[9] The NIH budget increased by only $150 million (0.5%) in 2015, significantly less than the $606 million increase approved by the Senate spending committee and $211 million requested by the White House. This increase still resulted in a budget level below that in 2012.[10] In fact, in inflation-adjusted dollars, the NIH budget is >22% below the 2003 level.[8]

We found a strong positive correlation between the number of grant proposals submitted and the rate of achieving extramural funding support. This is an important observation that needs to be emphasized to young surgeons seeking to establish successful research careers. Historically, surgeons have not applied as often as their nonsurgical peers.[4,5,11] This likely contributes to the fact that only 46% of all faculty surveyed, and 69% of basic scientists, had extramural funding. Although "success" in basic research is difficult to define, we use federal funding as a proxy, but accept that alternative revenue sources (private industry, philanthropy, clinical revenue) can sustain productive basic research programs. Nevertheless, achieving peer-reviewed federal funding is commonly accepted as indicative of a successful research effort. Based on this metric, and the data presented here and previously by others, surgeon-basic scientists are falling behind and the future of this important aspect of academic surgery is uncertain.

Recognizing that multiple challenges confront surgeon-scientists, the SUS formed a Basic Science Committee tasked with identifying the issues facing surgical investigators to inform potential solutions. Established in 1938, the SUS is one of the premier organizations dedicated to the advancement of the surgical sciences. Its members have held an essential role in the development of modern surgery, contributing scientific breakthroughs and technological advances.[12] Formed in 1966 with a similar mission, the AAS promotes a vision of research and academic pursuits through the exchange of ideas between surgical residents, junior faculty, and established academic surgeons.[13] The ASC is the annual academic meeting jointly sponsored by these 2 organizations, representing the largest cohort of academic surgeons in North America. Two previous studies surveyed academic surgeons on the topic of surgeon-scientists. Ko et al (2000)[14] invited 850 senior members of the AAS, SUS, and the American Surgical Association to complete a questionnaire, achieving a 44% response rate. In this survey, conducted over 15 years ago, academic surgeons believed that basic science research is a valuable pursuit. However, clinical and administrative responsibilities represented significant barriers to their research success. What was notably absent was the issue of research funding, a problem that has become much more pressing since that publication. The second study, by Chokshi et al (2009),[12] sent an online survey to 1381 SUS members, with 23% responding. In this study, the authors again noted the burden of clinical activities, with participants spending at least twice as much time on clinical care than in research, partly because of the pressure to be financially productive. The present study adds important new information to this body of knowledge. It includes results from >1000 respondents, representing the largest survey to date focused on scientific research among surgeons. Furthermore, this survey gauges the perceptions of surgeons with regard to basic science research in light of growing clinical and financial pressures, mounting administrative burden, and importantly increasingly challenging national funding environment.

To formulate solutions to the challenges facing surgeon-scientists, identifying the external pressures that limit opportunities for success is a priority. These pressures impact a surgeon's ability to succeed primarily by limiting the amount of time they can dedicate to their research. Pressure from department and hospital leadership to generate clinical revenue, often exacerbated by insufficient financial incentives for faculty to be academically productive, has previously been identified as one of the factors that adversely impact an investigator's research effort.[4,12,14,15] Increased administrative duties also impact research activities.[4,6,12,14] We similarly found that surgeon-scientists feel that the pressure to be clinically productive and the burden of excessive administrative responsibilities both adversely affect their ability to be productive scientifically. We also identified a focus on the impact of basic research on work-life balance, especially among younger respondents, further limiting the time and motivation for research. Finally, the difficulty of obtaining funding has become a major impediment. These obstacles make basic/translational research increasingly difficult to pursue and ultimately cause not only current, but also aspiring, surgeon-scientists to question their motivation to pursue basic science.

One of the most surprising, and concerning, findings is that 68% of academic surgical faculty believe it is unrealistic for a surgeon to be a successful basic researcher. This is even more concerning when taking into consideration that this perception is prevalent even among those who consider themselves basic scientists. Furthermore, it is troubling that 65% of department leaders share this view. Changing this broad perception will be difficult without surgical chairmen/directors asserting the importance of basic investigation as integral to their programs.[16] This negative perception may partly underlie the declining proportion of surgeons performing basic research during residency. Whereas 75% of division/department leaders did basic science during residency, only 60% of junior faculty and 53% of trainees did so. Given the finding that most academic surgeons remain in a research field similar to what they did during training, the decrease in basic research among our future surgeons and leaders is another reason for concern.

This study has several limitations owing to the nature of a survey and the inherent methodologic issues. There may have been potential bias in who responded. For example, 42% of respondents indicated basic science as their primary research focus, a relatively high proportion. Also, the responses are self-reported and therefore subject to variability and inconsistency. Nevertheless, this study reflects the opinions of a large cohort of academic surgeons and represents the prevailing perceptions and experiences of that group regarding critical barriers confronting surgeons pursuing basic/translational research. These barriers include the difficult funding environment, excessive clinical demands, and an overall belief that surgeons cannot succeed in basic science. Leaders in academic surgery need to be aware of these challenges so that an informed discussion can begin at the department, hospital, and national levels on how best to address them. Surgeon-scientists also need to do their part to enhance their likelihood of success. This includes increasing their frequency of grant applications and engaging more closely with appropriate mentors, both of which were found by our study to be associated with funding success; and both of which could be used as performance metrics by department leaders.

As mentioned above, the changing academic and hospital environment has contributed to a prevailing perception that it is unrealistic for surgeons to succeed as basic scientists, and may have surgeons wondering whether it is even worthwhile to maintain and develop links between basic science and surgery. If such attitudes permeate surgical leadership, it will influence the justification for making the investment required to encourage young faculty along a path toward basic science inquiry and research independence. Current models for surgical training need to be evaluated and possibly changed to develop surgeon-scientists prepared to succeed in today's competitive scientific environment.[17–19] If we agree that fundamental investigation into the pathophysiology and treatment of surgical disease needs to include the active participation of surgeons, then academic surgery must act to address these challenges and ensure the continued development of surgeon-scientists and an environment that promotes their success.

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