The explosion of biomedical knowledge in the past decade has brought with it promises of personalized medicine, new developments in therapeutics in the area of biology such as the use of monoclonal antibodies and stem cells and more biological approaches to the management of bone and joint disease. The complexity of biomedical research today to bring therapies from the bench to the bedside requires a team of scientists, engineers and clinicians working closely together. The authors of this review make a case for training a breed of orthopaedic clinician scientists “who will play an important role in bridging the gap between laboratory science and the clinic”, who also understand the “regulatory environment” and “possess the required skill set to translate scientific discovery to evidence-based orthopaedic surgery”. It seems a tall order to expect one single individual to be able to acquire the expertise to fulfill all these roles.
While it is logical and even desirable to have such a breed of surgeons who have the ability to understand basic science as well as translational and clinical research, many obstacles stand in the way of this desired outcome. Ahn et al1,2 in two separate studies made a case for trying to attract and incentivise MD PhD students to choose orthopaedic surgery as a career. Interestingly, many of the students interviewed in this study preferred more clinical than research involvement in their future practices. For a research career, availability of research funds and protected time for research were the main incentives mentioned. The question to ask is whether it possible to produce and sustain enough clinicians with a strong interest in research and provide a career path for them?
The clinician scientist is expected to fulfill certain roles which can be listed as follows:
1) Form the bridge between the scientists and the clinicians
2) Ask appropriate scientific questions based on clinical experience
3) Identify clinical problems and take them to the laboratory to find solutions
4) Apply scientific findings to the treatment of patients
5) Provide leadership and co-ordination of the research team
6) Perform clinical trials to validate research findings
There are currently a number of avenues to produce individuals who may have some if not all of these attributes. One is the MD PhD program offered by many US medical schools, which will generally produce a “medical scientist” i.e. someone with medical training who understands science. Many of the graduates spend most of their time doing basic research as they only have basic medical knowledge. The current thinking is leaning towards training an individual who has a medical degree, a postgraduate specialty qualification as well as a postgraduate training in research. This may take the form of a Masters or PhD in Clinical Investigation or a PhD in the more basic science disciplines. The former will produce a clinician investigator who will be armed with the necessary knowledge to undertake health services research or design and conduct clinical trials while the latter will fulfil the role of a clinician scientist. A possible third route may be immersing someone with medical undergraduate and postgraduate qualifications in fulltime bench research for one to two years without culminating in a PhD. In addition, it would also be desirable to have basic scientists spend some time in clinical departments to learn more about clinical medicine. A clinician scientist can best fulfil his role if he spends a proportion of his time in the clinic. Having a mixture of such individuals in academic medical centres would add much more value to the multidisciplinary team required to pursue biomedical research today.
In order to achieve the desired outcome of having more clinicians involved in research, a coordinated approach is necessary. This will necessitate an alignment in thinking, a shared purpose with a willingness to participate by all the stakeholders involved in medical education, postgraduate medical training and the health service providers. The US has led the way to some extent with their MD PhD programs, postgraduate courses in clinical investigation as well as basic research. The National Institute of Health (NIH) through the National Centre for Research Resources (NCRR) has recently launched Clinical and Translational Science Awards (CTSA) which will train clinician scientists through a consortium of medical research institutions.3 The UK has started a clinician scientist scheme by providing academic clinical fellowships for the early part of the specialty training program and clinical and senior clinical lectureships to academic physicians/surgeons who wish to spend 50% of their time in research4 and Canada also provides clinician scientist training awards.5 Recognising the need for such expertise Singapore has also initiated several programs to train and incentivize clinician investigators and clinician scientists. These awards are given through the National Medical Research Council (NMRC).6
Having put in place a programme to train such individuals, the challenge is how to retain them in the research environment and sustain a pipeline of such individuals coming out of medical school. Having good mentors and role models is of paramount importance but this is not enough. The clinician who spends time doing research should be rewarded with a comparable financial incentive to their clinical colleagues. This is even more true for orthopaedic surgery as it is one of the more lucrative specialties. Opportunities to access research funding and protected time for research are mandatory requirements to sustain the research activity of the clinician scientist. The difference in the expectations between academic institutions and hospitals in terms of research vs clinical service commitment has to be resolved. Finally a proper career path for clinician scientists has to defined.
Taking the discoveries from the bench to the bedside involves more than just research expertise. The research team needs to have a good understanding of intellectual property protection, regulatory issues in pre-clinical development and clinical trials for drugs and medical devices. In this regard, a strong research collaboration or partnership with industry becomes crucial as the industrial partners will be able to provide and skills and expertise to take the innovation to the market. The clinician scientist cannot be expected to have the required expertise to accomplish all this, but he can certainly fulfill the role as a leader or coordinator in this very important innovative chain.
1. Ahn J, Man LX, Wanderer J, Bernstein J, Iannotti JP. The future of the orthopaedic clinician-scientist. Part I: The potential role of MD-PhD students considering orthopaedic surgery. J Bone Joint Surg [Am] 2008;90-A:1794-9.
2. Ahn J, Donegan DJ, Lawrence JT, Halpern SD, Mehta S. The future of the orthopaedic clinician-scientist Part II: Identification of factors that may influence orthopaedic residents' intent to perform research. J Bone Joint Surg [Am] 2010;92-A:1041-6.
3. NIH Clinical and Translational Science Awards, www.ctsaweb.org
4. NIHR Research Training Awards, www.nihr.ac.uk
5. CIHR Clinician Scientist Training Award, www.cihr-irsc.gc.ca
6. NMRC – Ministry of Health Clinician Scientist Awards, www.nmrc.gov.sg
Lee EH, Professor
Department of Orthopaedic Surgery, National University Health System, Singapore