Transplant surgeons not only have improved the practice of transplantation and developed new surgical techniques, but they have also made significant scientific advances in the areas of immunology, infectious diseases, and physiology. These efforts have led to modern transplant surgery, saving many lives. There is still exciting scientific progress in many areas, including biostatistics, artificial organs, and immune tolerance. There is a need for new scientific ideas that are based on clinical insights. However, it is not clear if young surgeons will be able to contribute to these important efforts.
Anecdotal conversations led us to the conclusion that while many talented and young surgical trainees dedicate a significant portion of their postgraduate work towards research, very few continue these efforts in their faculty years. We focused our attention on the K-award (the most important career development award of NIH), which was designed to investigate the issue. K-awards provide protected research time over 3 years and are currently funded by more than 5000 people. Many highly successful physician-scientists use their K-award period training and preliminary data to prepare competitive applications in the NIH Independent Investigator (R-level). Although the NIH career pathway is not the only route to a career as a researcher it is used by many well-known scientists in the United States. It is also required by many academic centers for tenure track promotion.
Transplant Surgeons-accredited fellowships in transplant surgery with the NIH funding database to address this problem. If investigators had the skills and research background to be awarded an independent investigator award, we also looked at K awards that were successfully funded. To better understand the priorities and attitudes of young ASTS members, we also conducted a survey. This survey examined research experiences during residency and medical school, graduate research training, protected times, and correlations between allocated research time and desired research time. Survey respondents were asked to identify the barriers that prevent funding and the successful conduct of research. The study's overall purpose was to better understand the funding needs of young transplant surgeons. It also sought to identify possible system barriers that could prevent them from obtaining desired research funding.
Only 10 of the 373 transplant surgeons who completed their fellowships in 7 years were awarded NIH funding to be principal investigators of a K or R-level career development award. Compared to the 10,252 K awards, 76,404 R awards, and 76,404 R awards, only 10 seem to be young transplant surgeons. Many of these had completed research training and graduated degrees before they were appointed to faculty.
These findings can be interpreted in many ways. The first is that there may not be enough interest in NIH-funded research careers. Research years are a requirement of many academic residencies. Therefore, a high participation rate (nearly 80%) in research time during residency may be misleading. It is possible, however, that not many young transplant surgeons want to pursue research careers. Although funding is a small denominator, 78% of the survey respondents said they wish they had more research time. 60% stated that they had had less research time after completing their fellowship.
This discrepancy points to another possible interpretation: transplant surgeons may want to participate in research (perhaps to enjoy publishing or to gain 'academic currency'), but they are not committed to becoming researchers. The actions speak louder than the words. One argument could be made that anyone serious about research will get a research-oriented graduate program, spend several years in research training (beyond the mandatory 'working in someone’s lab' during residency), publish multiple manuscripts, interact with mentors (at the institution and beyond) and eventually be a strong candidate for the NIH career pathway.
Although the above interpretations, a low denominator, or unrealistic expectations could play a part in explaining the observed data. However, the low NIH funding rates for young surgeons (less than one thousand dollars per year) can't be explained by these variables alone. Transplant surgeons are intelligent, hardworking, and motivated. They have been proven to be capable of a rewarding research career if given the right environment. Our survey revealed that only 21% of young transplant surgeons believe that research success with current resources is possible. However, 63% think that success would be possible if they had the right resources, mentorship, or protected time. It is not clear how to define "appropriate resources, mentorship and protected time".
It is interesting to note that all K awards in our study were K08 for laboratory science. There is a strong interest among American young surgeons to do clinical research. The K23 award from the NIH could help. The classic paradigm of surgical table science may be functional. There is a strong network of mentors and a track record of success, but clinical research transplant surgeons lack mentorship from the transplant community. This means that there may be a large pool of senior transplant epidemiologists, but not enough senior transplant immunologists.
Our research shows that young transplant surgeons see significant obstacles to their careers as researchers. They cite a lack of mentorship and clinical workload as major obstacles to their research careers. The environment for transplant research could change. One possible approach is to create comprehensive transplant centers, which are similar to the comprehensive cancer center model. These centers would be built within transplant programs that have a strong research focus. They would be funded to provide broad-based scientific infrastructure as well as collaborations in transplantation. Young transplant surgeons might be able to benefit from such coordinated, broad-based research.
Transplant surgery isn't the only specialty that has concerns about the future of the young. In general, M.D. M.D. applicants are less likely to be funded by the NIH than Ph.D. applicants. Surgeons are less likely than other clinicians to apply for NIH funding. Furthermore, surgical applications have the lowest funding rates of any clinical specialty. As a result, surgeons are not represented on NIH councils and study sections. Both the cardiothoracic and vascular surgeons' professional societies expressed concern about the low funding rates from NIH for their younger members. However, NIH grants have been awarded to significantly more young vascular and cardiothoracic surgeons in recent years than transplant surgeons. For example, 39 NIH career advancement awards were received by young vascular surgeons over six years, with a funding rate of 49%.
Financial pressures at the institution level may have an impact on the career paths of many young transplant surgeons. Many large medical centers have transplantation as a major clinical and financial focus. In this environment, young transplant surgeons often have to focus on clinical productivity. Due to the complexity of both transplant surgery as well as patient management, clinical expertise is required. Surgeons who do not engage in clinical care are less well-suited for clinical transplant surgery. Our study found that young surgeons report that their time is consumed by clinical surgery, with little left for research. The practice environment has changed, with more surgical residents and more demand for hands-on attending participation.
Similar to the NIH, there is a possibility that the career development paradigm for young transplant surgeons is not well aligned. K-level awards require 75% commitment. Young surgeons and transplant clinic staff may find it difficult to meet the 75% 'protected time requirements due to the intense nature of transplant surgery and the frequent calls. K-level awards are required to 75% of a surgeon's efforts, but they only contribute $83,000 towards salary. This means that the hospital's clinical department must fill the gap in salary. It also requires sisalary gapding commitments to research development. Young transplant surgeons may consider society- or pharmaceutical-supported research more convenient funding options. The NIH has stated a commitment to the development of the physician-scientist through its K program. It seems to work as half of the K awardees in the study received R-level grants, while far fewer ASTS grant recipients were subsequently awarded R-level grants. The NIH may consider alternative funding mechanisms for career development that are more in line with the path of transplant surgeons. The National Institute of Diabetes and Digestive and Kidney Diseases, for example, allows 'urologic surgeons to reduce the effort required to award K-level awards by 50%. Perhaps other institutes will follow this lead.
We have found that very few young transplant surgeons can obtain NIH funding despite having received thousands of awards and significant research experience in their training. Although the reasons are still unclear, it is up to the transplant surgery community to respond to these findings and decide if this level of research participation is what we want for our field.
Sources:
https://www.facs.org/media/press-releases/2021/nih-funding-021221
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/transplant-surgeon
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