Facilitating Success of the Early Stage Surgeon Scientist Trainee: Growing the Surgeon Scientist Pipeline

National Institutes of Health Funding for Surgeon-Scientists in the US-An Update and an Expanded Landscape

Importance

Current reports suggest that the surgeon-scientist phenotype is significantly threatened. However, a significant increase in the proportion of surgeons in the workforce funded by the National Institutes of Health (NIH) from 2010 (0.5%) to 2020 (0.7%) was recently reported and showed that surgeons primarily performed basic science research (78% in 2010; 73% in 2020) rather than clinical research.

Objective

To provide an update on the status of surgeons funded by the NIH for fiscal year (FY) 2022.

Evidence Review

NIH-funded surgeons were identified in FY2012 and FY2022, including those who were awarded grants with more than 1 principal investigator (PI) by querying the internal database at the NIH. The main outcome for this study was the total number of NIH-funded surgeons in FY2012 and FY2022, including total grant costs and number of grants. The secondary analysis included self-reported demographic characteristics of the surgeons in FY2022. The research type (basic science vs clinical) of R01 grants was also examined.

Findings

Including multiple PI grants, 1324 surgeon-scientists were awarded $1.3 billion in FY2022. Women surgeons increased to 31.3% (339 of 1084) of the population of surgeon PIs in FY2022 compared with 21.0% (184 of 876) in FY2012. Among surgeon PIs awarded grants, a total of 200 (22.8%) were Asian, 35 (4.0%) were Black or African American, 18 (2.1%) were another race (including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and more than 1 race), and 623 (71.1%) were White. A total of 513 of 689 R01 grants (74.5%) were for basic science, 131 (19.0%) were for clinical trials, and 45 (6.5%) were for outcomes research.

Conclusions and Relevance

NIH-funded surgeons are increasing in number and grant costs, including the proportion of women surgeon PIs, and are representative of the diversity among US academic surgical faculty. The results of this study suggest that despite the many obstacles surgeon-scientists face, their research portfolio continues to grow, they perform a myriad of mostly basic scientific research as both independent PIs and on multidisciplinary teams.

Transforming the Future of Surgeon-Scientists

OBJECTIVE

To create a blueprint for surgical department leaders, academic institutions, and funding agencies to optimally support surgeon-scientists.

BACKGROUND

Scientific contributions by surgeons have been transformative across many medical disciplines. Surgeon-scientists provide a distinct approach and mindset toward key scientific questions. However, lack of institutional support, pressure for increased clinical productivity, and growing administrative burden are major challenges for the surgeon-scientist, as is the time-consuming nature of surgical training and practice.

METHODS

An American Surgical Association Research Sustainability Task Force was created to outline a blueprint for sustainable science in surgery. Leaders from top NIH-sponsored departments of surgery engaged in video and in-person meetings between January and April 2023. A strength, weakness, opportunities, threats analysis was performed, and workgroups focused on the roles of surgeons, the department and institutions, and funding agencies.

RESULTS

Taskforce recommendations: (1) SURGEONS: Growth mindset : identifying research focus, long-term planning, patience/tenacity, team science, collaborations with disparate experts; Skill set : align skills and research, fill critical skill gaps, develop team leadership skills; DEPARTMENT OF SURGERY (DOS): (2) MENTORSHIP: Chair : mentor-mentee matching/regular meetings/accountability, review of junior faculty progress, mentorship training requirement, recognition of mentorship (eg, relative value unit equivalent, awards; Mentor: dedicated time, relevant scientific expertise, extramural funding, experience and/or trained as mentor, trusted advisor; Mentee : enthusiastic/eager, proactive, open to feedback, clear about goals; (3) FINANCIAL SUSTAINABILITY: diversification of research portfolio, identification of matching funding sources, departmental resource awards (eg, T-/P-grants), leveraging of institutional resources, negotiation of formalized/formulaic funds flow investment from academic medical center toward science, philanthropy; (4) STRUCTURAL/STRATEGIC SUPPORT: Structural: grants administrative support, biostats/bioinformatics support, clinical trial and research support, regulatory support, shared departmental laboratory space/equipment; Strategic: hiring diverse surgeon-scientist/scientists faculty across DOS, strategic faculty retention/ recruitment, philanthropy, career development support, progress tracking, grant writing support, DOS-wide research meetings, regular DOS strategic research planning; (5) COMMUNITY AND CULTURE: Community: right mix of faculty, connection surgeon with broad scientific community; Culture: building research infrastructure, financial support for research, projecting importance of research (awards, grand rounds, shoutouts); (6) THE ROLE OF INSTITUTIONS: Foundation: research space co-location, flexible start-up packages, courses/mock study section, awards, diverse institutional mentorship teams; Nurture: institutional infrastructure, funding (eg, endowed chairs), promotion friendly toward surgeon-scientists, surgeon-scientists in institutional leadership positions; Expectations: RVU target relief, salary gap funding, competitive starting salaries, longitudinal salary strategy; (7) THE ROLE OF FUNDING AGENCIES: change surgeon research training paradigm, offer alternate awards to K-awards, increasing salary cap to reflect market reality, time extension for surgeon early-stage investigator status, surgeon representation on study section, focused award strategies for professional societies/foundations.

CONCLUSIONS

Authentic recommitment from surgeon leaders with intentional and ambitious actions from institutions, corporations, funders, and society is essential in order to reap the essential benefits of surgeon-scientists toward advancements of science.

Funding a general surgery residency academic development time program

BACKGROUND

To encourage progression of surgeon scientists amongst increasingly limited funding, academic interest, training institutions are supporting mid-training academic development time (ADT). We propose that supporting ADT with a full funding mechanism will improve ADT participation at minimal institutional cost.

MATERIALS AND METHODS

From 2017 to 2022, our surgery department proposed a full funding mechanism for a post-graduate year three (PGY-3) resident to encourage ADT participation. Residents were required to submit at least two external grants. Annual funding sources and total stipend supplementation was calculated by prevalence of ADT residents.

RESULTS

From 2017 to 2022, 30 residents opted to participate in 1-4 years of ADT with increasing prevalence. 5 funding sources were utilized with ∼$530,000 in total annual funding. Departmental contribution was minimal compared to external (9% vs. 91% ($48,102 vs. $485,573, p ​< ​0.001)).

CONCLUSIONS

With commitment of full salary supplementation, residents choosing ADT increased at marginal institutional cost, suggesting a solution to combating the declining number of academic surgeons.

Orthopedic surgeon-scientist representation is low among National Institutes of Health grants for rotator cuff research

Background

The purpose of this study is to characterize National Institutes of Health (NIH) funding for rotator cuff research and evaluate the impact of orthopedic surgeons on this portfolio.

Methods

The NIH's Research Portfolio Online Reporting Tools Expenditures and Results database was queried for "rotator cuff repair" or "rotator cuff tear" from the 2011 to 2021 fiscal years. Compound annual growth rates were calculated and grants were categorized by basic, clinical, or translational research. Funding totals were compared by Principal Investigator (PI) and grant characteristics.

Results

A total of 52 grants were awarded to 38 PIs between 2011 and 2021, totaling $40,156,859. Annual NIH funding for rotator cuff tear and rotator cuff repair increased by a Compound annual growth rate of 11.0% from 2011 to 2021, compared to 3.4% for the total NIH budget. Orthopedic surgeon-scientists received $9,208,212 (22.9%), most commonly through R01 (80.5%) and K08 (7.1%) mechanisms. No significant difference in funding was found by PI sex (P = .332), degree (P = .460), academic rank (P = .118), or researcher type (P = .227). Professors had a higher h-index than associate and assistant professors (P = .001). Orthopedic surgeon-scientists had a higher h-index (mean 36.3 ± 9.4) compared to clinician-scientists (mean 8.0 ± 1.4) and research-scientists (35.5 ± 40.7) (P = .044). Clinical topics receiving the highest funding were rehabilitation (23.9%), diagnosis, (22.3%) and surgical technique (14.8%). Orthopedic surgeon-scientists acquired funding for diagnosis (57.1%), rehabilitation (17.0%), and surgical technique (14.5%).

Discussion

While NIH funding for rotator cuff research is growing, orthopedic surgeon representation is low. Future studies should evaluate barriers to obtaining funding for orthopedic surgeon-scientists.

Preserving the Pipeline of Surgeon Scientists: The Role of a Structured Research Curriculum

INTRODUCTION

With shrinking National Institute of Health support, increased clinical demands, and less time for research training during residency, the future of surgeon scientists is in jeopardy. We evaluate the role of a structured research curriculum and its association with resident academic productivity.

METHODS

Categorical general surgery residents who matched between 2005 and 2019 at our institution were analyzed (n = 104). An optional structured research curriculum, including a mentor program, grant application support, didactic seminars, and travel funding was implemented in 2016. Academic productivity, including the number of publications and citations, was compared between residents who started in or after 2016 (postimplementation, n = 33) and those before 2016 (preimplementation, n = 71). Descriptive statistics, Mann-Whitney U test, multivariable logistic regression, and inverse probability treatment weighting were performed.

RESULTS

The postimplementation group had more female (57.6% versus 31.0%, P = 0.010), and nonwhite (36.4% versus 5.6%, P < 0.001) residents and had more publications and citations at the start of residency (P < 0.001). Postimplementation residents were more likely to choose academic development time (ADT) (66.7% versus 23.9%, P < 0.001) and had higher median (IQR) number of publications (2.0 (1.0-12.5) versus 1.0 (0-5.0), P = 0.028) during residency. After adjusting the number of publications at the start of residency, multivariable logistic regression analysis showed that the postimplementation group was five times more likely to choose ADT (95% CI 1.7-14.7, P = 0.04). Further, inverse probability treatment weighting revealed an increase of 0.34 publications per year after implementing the structured research curriculum among residents who chose ADT (95% CI 0.1-0.9, P = 0.023).

CONCLUSIONS

A structured research curriculum was associated with increased academic productivity and surgical resident participation in dedicated ADT. A structured research curriculum is effective and should be integrated into residency training to support the next generation of academic surgeons.

Postdoctoral National Institutes of Health F32 Grants: Broken Pipeline in the Development of Surgeon-Scientists

OBJECTIVE

We examined trainees in surgery and internal medicine who received National Institutes of Health (NIH) F32 postdoctoral awards to determine their success rates in obtaining future NIH funding.

BACKGROUND

Trainees participate in dedicated research years during residency (surgery) and fellowship (internal medicine). They can obtain an NIH F32 grant to fund their research time and have structured mentorship.

METHODS

We collected NIH F32 grants (1992-2021) for Surgery Departments and Internal Medicine Departments from NIH RePORTER, an online database of NIH grants. Nonsurgeons and noninternal medicine physicians were excluded. We collected demographic information on each recipient, including gender, current specialty, leadership positions, graduate degrees, and any future NIH grants they received. A Mann-Whitney U test was used for continuous variables, and a χ 2 test was utilized to analyze categorical variables. An alpha value of 0.05 was used to determine significance.

RESULTS

We identified 269 surgeons and 735 internal medicine trainees who received F32 grants. A total of 48 surgeons (17.8%) and 339 internal medicine trainees (50.2%) received future NIH funding ( P < 0.0001). Similarly, 24 surgeons (8.9%) and 145 internal medicine trainees (19.7%) received an R01 in the future ( P < 0.0001). Surgeons who received F32 grants were more likely to be department chair or division chiefs ( P =0.0055 and P < 0.0001).

CONCLUSIONS

Surgery trainees who obtain NIH F32 grants during dedicated research years are less likely to receive any form of NIH funding in the future compared with their internal medicine colleagues who received F32 grants.