Wearing two hats, part 1

While I am on vacation, I'm reprinting a number of "Classic Insolence" posts to keep the blog active while I'm gone. (It also has the salutory effect of allowing me to move some of my favorite posts from the old blog over to the new blog, and I'm guessing that quite a few of my readers have probably never seen many of these old posts.) These will appear at least twice a day while I'm gone (and that will probably leave some leftover for Christmas vacation, even). Enjoy, and please feel free to comment. I will be checking in from time to time when I have Internet access to see if the reaction to these old posts here on ScienceBlogs is any different from what it was when they originally appeared, and, blogging addict that I am, I'll probably even put up fresh material once or twice.

People don't understand what I do very well.

I wear two hats. I'm a surgeon, and I'm a scientist.

By this I don't mean that people don't understand what it is that a doctor or a surgeon does. (Everyone knows that a doctor takes care of patients, after all.) I also don't mean that they don't understand what a basic scientist does (although most of them do seem to have some sort of an odd picture of me in a lab with test tubes and brightly colored solutions bubbling in the background, the same misconception that is common about pure basic scientists). In fact, I would go so far as to say that even most doctors and most basic scientists probably don't understand the difficulties of combining a clinical career with laboratory research, because those of us who try to do both are in a distinct minority. The vast majority of doctors do only clinical practice, and basic scientists will never have the responsibility of caring for patients. Even among the minority of doctors who do research, the majority do mainly clinical research (testing new therapies in clinical trials, for example), and that is what most people are thinking of when they think of doctors doing research.

Combining a laboratory research career with a clinical career has always been difficult, but these days it's become a Herculean challenge. One aspect of biomedical research not understood by most lay people is that basic scientists in academia doing research are usually expected to pay most or all of their own salaries and laboratory overhead through grant support, preferably from the NIH. In some smaller colleges, there are faculty whose primary responsibility is to teach, but the big universities require research and grant funding to support that research. If young faculty members don't demonstrate the ability to compete for such grant support, they don't get tenure. Usually, they get a startup package with enough support to keep their lab going for perhaps three to five years. After that, they are expected to be able to fund their own laboratories. The bottom line is: If they can't, no tenure. Yes, there are other requirements for tenure, such as peer-reviewed scientific publications of sufficient number and quality, science good enough to win the respect of peers, and evidence of teaching talent, but the bottom line is: If you can't attract enough funding, the other stuff won't even be considered.

Now, consider the clinician-scientist. We have to compete for grant money with the same hungry basic scientists who can spend the vast majority of their time doing research. Worse, most of the reviewers in the study sections that decide which grant applications get funded are basic scientists. Yet, a large proportion of our time is taken up caring for patients. Those of us who have not undergone formal Ph.D. training may not have adequate experience in formulating a research plan in a logical and compelling narrative that can convince a study section that (1) we have a reasonable hypothesis; (2) we have evidence to support the hypothesis; and (3) we can formulate a scientifically credible plan to study that hypothesis. And we have to do this while devoting half (or more) of our time to patient care. Consequently, many basic scientists look at doctors (especially surgeons) with condescension. ("Oh, isn't that precious! He's trying to do serious research!") Unfortunately, occasionally, that condescension is deserved--but it is not deserved nearly as often as some basic scientists seem to think.

There was a time twenty or thirty years ago that clinician-scientists could be supported by slush funds derived from the clinical income of the department in which they worked. This was especially true of surgery departments, which were often revenue machines. Those days are long gone. Academic medical centers have to live in the same world as private hospitals, and managed care companies are not willing to pay them more, even with their increased overhead. There is often little or nothing left over for research after paying the bills--if the department is lucky enough and well-managed enough not to be in the hole. In fact, academic physicians are generally expected to bring in enough revenue to cover their own salary and expenses. Given that the actual collection rate for what is billed may be only $0.25 to $0.40 on the dollar (or even less), for a surgeon, covering one's own salary, one's secretary's salary and overhead, office overhead (yes, the University charges office rent), and other expenses can require billing for as much as $500,000 to $1 million a year--or even more. Busy clinicians can do it. Half-time clinicians don't have a prayer, particularly if they have the added overhead of a laboratory. That means the department must be willing to support research. Busy clinicians in the department must buy into the vision and be willing to subsidize the development of new clinical researchers with some of the fruits of their own clinical productivity.

What about grant support? Well, that can help, but you can only ask for salary support for the percentage of your time that is devoted to the research project. Consequently, if you are 50% clinical, there is no way you can ever support your entire salary, as basic scientists can. The most you can ever support is 50%. Rare clinician-scientists can support maybe 70% of their salary. But it's worse than that. Most clinicians make an academic base salary, plus a salary that comes from clinical revenue. Grant support can only be applied to academic base salary. Consequently, clinicians can rarely cover more than 20-40% of their total salary with grant support. Again, even with an NIH grant, almost no clinician-scientist can cover his own overhead through clinical activity and grant support, even very successful ones.

Of course, as clinician-scientists, we do have an advantage over basic scientists in one area. We understand the clinical management of the disease we're studying in an up-close and personal way that the basic scientist can never match. We deal with patients with the disease and watch the course of the disease every day. We know the deficiencies in present therapies and issues needing more attention in a way that basic scientists can never truly understand, because they don't have first-hand experience with them. We make observations about the disease that basic scientists never will. (Indeed, the flipside of the condescension basic scientists all too often show towards clinicians doing basic research is the contempt clinicians sometimes show towards the way basic scientists tend to focus on mechanism rather than practical results. We want new therapies now because patients are suffering and dying now, and are often impatient with the leisurely pure science basic scientists love.) This is not an insignificant factor, given the reorientation of the NIH in recent years towards research that is likely to lead to treatments sooner rather than later. Nonetheless, overall, the forces arrayed against the success of clinician scientists are formidable indeed.

Perhaps the most formidable challenge is finding enough "protected time" (time with little or no patient care responsibility that is "protected" for research). One of the hardest tasks a young clinician-scientist has is to protect his research time from the inevitable intrusions of patient care. If he doesn't, then one day he will wake up to realize that he hasn't been in his laboratory for anything other than brief visits for over a month; that his entire schedule has been taken over by patient care demands; and that his lab is almost out of money because he never had time to produce enough preliminary data to write a competitive grant application. Having adequate protected time is impossible unless a young faculty member's chairman and division understand the need for protected time and help to protect research time. Sometimes that means laying down the law that new patients beyond a certain number will be seen by other surgeons. Without the chairman's support, even the best effort to protect research time will likely fail. I've seen it several times with colleagues and friends. Driven by the unfortunate financial reality of academic surgery today, their chairmen or division chief, while voicing lip service to the desire to provide protected time for research, kept demanding more and more clinical revenue, which meant seeing more and more patients. For a while they would try to make up for it by working late nights and weekends, but eventually something had to give. In these cases, what usually "gives" is research. They give it up and usually become primarily clinicians. Sometimes the rare surgeon-scientist with an exceptional devotion to and talent for research will take the pay cut and become a pure basic scientist. I've been extraordinarily fortunate so far in that all my bosses and the institution have done their best to help me protect my research time, and they've given me nearly five years to obtain support.

In some ways, I think that surgeons trying to do research have it worst of all. In the medical specialties, it is often possible to arrange schedules so that doctors doing research only have concentrated clinical duties one or two months out of the year, with the rest of the year serving as protected time. In surgery, such huge chunks of protected time are rarely possible (outside of V.A. or county hospitals) for several reasons. First, surgery is personal. Patients don't want just any surgeon operating on them. They want a specific surgeon that they've come to trust. Consequently, the clinical burden is ongoing throughout the year, leading to us trying to protect days at a time, rather than weeks or months at a time. Second, even if we could arrange our schedules the way medical doctors do, our specialties are skill- and task-oriented. Our surgical skills would atrophy. (Indeed, clinical surgeons sometimes look down on surgeon-scientists as not having the same level of surgical skills they do.) Finally, surgeons have a very special relation to their patients. If a patient I operate on has a postoperative complication, I'm going to take care of it, unless for some reason I'm on vacation or out of town (and for some surgeons, even those are not always barriers to taking care of their own). It doesn't matter if I'm on call or not, if it's the middle of the night or not, or if it's during the weekend or not. That's just the nature of surgery as a specialty. Although my specialty has relatively few emergencies, for other surgical specialties, just this aspect of surgery alone can make a productive research career problematic. The bottom line is that we have to be just as good surgeons as pure clinicians while devoting only roughly half the time to it and just as good scientists as basic scientists--again, while dedicating only half the time to it. We rarely succeed at both to an equal degree.

So, why do I do it? I've often joked that, as an M.D. and a Ph.D., I catch crap from both worlds. (Clinicians don't think I know what I'm doing in the operating room, and basic scientists don't think I can hack it as a basic scientist.) So why put up with the stress of wearing two hats? Why not pick one or the other? There are two reasons. First, I think that clinician-scientists bring a unique perspective to the study of human disease that neither a clinician or a scientist alone can. Second, I want to make a difference. Nothing would be as satisfying as making a clinical observation, taking it to the laboratory, developing a treatment based on my laboratory observations, and then testing that in patients and seeing it work. I may never manage shepherd a treatment through all those stages (clinical observation, laboratory observations on the basic science, development of a therapy based on the science, and testing in clinical trials), but wouldn't it be great if, before I retire, I manage to pull it off? I certainly plan on spending the remaining decades of my career trying.

This post first appeared on February 7, 2005 on the old blog.