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The Otolaryngology Research Paradox
Robert M. Naclerio, MD;
Supinda Saengpanich, MD;
Mary Spainhour;
Fuad M. Baroody, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1181-1184.
ABSTRACT
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Objective To determine the attitude toward and the state of research within the
field of otolaryngology–head and neck surgery.
Design A questionnaire was sent to the chairpersons of departments of otolaryngology
where residency training is provided.
Participants and Setting Program directors of academic otolaryngology training programs.
Main Outcome Measure Responses to questionnaire.
Results Questionnaires were sent to 95 programs from which 86 responses were
received. Respondents believed strongly that research was important to the
specialty. Only two thirds of the full-time clinical faculty, however, do
research, and on average they devote only 17% of their time to this activity.
About a third of those doing research have funding, and the National Institutes
of Health support only 12% of clinician-investigators. Although program directors
believe that clinicians should do research, three fourths stated that clinicians
were too busy to accomplish this goal. Surprisingly, half of the respondents
were unaware of residency programs that offered 2 years of research training,
aimed to develop clinician-investigators, who can become competitive for attainment
of research funding.
Conclusions Although leaders within our specialty believe that research is important,
clinicians are not provided with enough time to conduct research. Furthermore,
pathways that would enhance their competitiveness to obtain research funding
are not recommended to our future clinicians.
INTRODUCTION
THE GENERATION of new knowledge is essential to the future of otolaryngology–head
and neck surgery. New knowledge, as a rule, occurs through time devoted to
research.
In 1982, Bailey1 believed that research
in otolaryngology was in a period of decline and sounded a call to action.
In 1991, Rosenfeld2 stated, "In an era of cost-effectiveness
and quality control, the need for sound clinical research as a basis for health
care decisions has intensified." To carry out clinically related research,
our specialty needs clinical investigators (scholars). These are individuals
whose primary activities include clinical care; the generation of new knowledge,
including publication of articles in peer-reviewed journals; and teaching.
In 1999, Nadol3 believed that there was an
undersupply of clinician-investigators and that the deficiency was worsening.
In 2000, Smith4 expressed concern that the
current medico-economic environment had adversely affected the academic health
care system, with decreased research funding and departmental support leading
many young otolaryngologists to question whether to pursue academic careers.
The need for clinician-investigators coupled with a changing academic environment
has created a potentially unfavorable situation.
To address the shortage of clinician-investigators, we as well as others
developed training programs that maintained the level of clinical training
required by our specialty board but added more research training. The research
training was chosen to last for 2 years, based on the Lenfant report.5 In essence, this report prepared for the National
Institutes of Health (NIH) suggested that future success in research, as judged
by the ability to obtain funding and make research a prolonged and substantial
part of one's career, was related to the duration of fellowship training;
ie, the longer the fellowship, the more successful the career. In fact, the
success rate in programs with training for less than 2 years was so poor that
the NIH elected to stop supporting them.
Since we began to offer 2 years of research training, we have noted
a decline in the number of applicants to our program, despite providing a
solid clinical and teaching experience. An informal telephone survey of six
7-year programs also showed decreased applicant enthusiasm for the 2-year
research component. To gain more insight into the difference between the perceived
need for clinician-investigators and the desire of applicants to pursue a
path toward that goal, we surveyed the directors of the otolaryngology residency
training programs.
METHODS
We developed a 16-item, single-page questionnaire that could be completed
within 5 minutes. We mailed the survey in June 2000 to 95 academic training
programs. In July, we sent a second survey to those who had not responded.
In total, we received 86 responses, a 91% yield.
We analyzed the data primarily by using descriptive statistics. Nonparametric
statistics were used. The Mann-Whitney test was used to evaluate differences
between groups. P .05 was considered significant.
RESULTS
A 100-mm visual analog scale anchored by the words "not important" (0)
and "critical" (100) was used to gauge clinicians' perceptions of the importance
of research to otolaryngology–head and neck surgery. A score of 87.5
(range, 29-100) was obtained, which suggested the importance of research (Figure 1). Using a similar scale, we asked
about the importance of research to the promotion of clinical faculty. The
score decreased to 70 (range, 12-100).
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Figure 1. The responses of the program directors
were assessed on a visual analog scale, given as medians and ranges.
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We next questioned the program directors about the number of full-time
clinical faculty in each program. The median number of clinical faculty members
per program was 8 (range, 4-21). The importance of research to the specialty
or to promotion did not vary for programs with 8 or more faculty members compared
with programs with fewer than 8 clinical faculty members (87 vs 85 and 70
vs 67, respectively). The median number of clinical faculty members doing
research was 5 (range, 4-21), or 63% of the clinical faculty. The clinical
faculty spent 15% (range, 5%-60%) of their time doing research, which is the
equivalent of less than 1 day per week. Only 12% had NIH-sponsored funding
for their research, whereas 30% had other sources of funding, and 58% had
none (Figure 2). Sixty-four (74%)
of the program directors stated that clinicians were too busy to do research.
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Figure 2. Percentage of clinical faculty
obtaining research funding.
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We also inquired about the faculty with PhD degrees in the programs.
The median number of faculty members with PhD degrees was 2 (range, 0-15).
Twenty-four percent of the faculty with PhD degrees had NIH funding. Only
4 (5%) of program directors believed that faculty members with a PhD degree
should be the only ones pursuing research in the program.
With the exception of the 7-year programs offering 2 years of research,
the programs offered, on average, 4 months (range, 2-16 months) of protected
time to pursue research training. Half of the respondents were unaware of
the 7-year programs that include 2 years of research training, and 53% stated
that they would not recommend them to medical students. Those not aware of
the existence of these programs tended to be the ones who would not recommend
them.
Eighty (95%) of the programs plan to recruit new clinical faculty in
the next 5 years. Thirty-eight (44%) will be looking for subspecialty-trained
candidates, and 19 (22%), for research-oriented generalists; 29 (34%) had
no preference (Figure 3).
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Figure 3. Preferences of the program directors
for potential faculty recruits in the next 5 years.
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COMMENT
While program directors recognize the importance of research, considering
it critical to our future, our clinical academic faculty members are spending
little time on research (slightly more than half a day per week), and most
of that time is unfunded. These observations seem paradoxical. If research
is important, then why don't we provide faculty with sufficient time to pursue
it successfully? The problem lies within our academic programs or in the individuals
we recruit.
Various publications provide some clues to the answer. Carney and colleagues6 reviewed the contribution of otolaryngologists of
the United Kingdom to the otolaryngology literature between 1985 and 1994
and found a significant trend toward more publications in clinical research
than in basic laboratory research. Rosenfeld2
reported a similar trend combined with a decline in articles on research with
grant support. On a positive note, he noted improved study designs. One interpretation
of these findings is that the basic sciences are becoming more complex and
that it is more difficult for clinicians to compete in this arena. Thus, our
current faculty are not trained to compete for funding and have focused their
efforts in the clinical arena.
Nadol3 approached the issue from the
perspective of faculty members who have been in practice less than 5 years.
In that group, the most common reason for entering academics was the desire
to teach. The factors identified for success most often by young faculty members
were clinical, teaching, and communication skills, not research training.
Thus, our young faculty members do not appear to be motivated to do research.
When young faculty members did research, their most common source of funding
was intradepartmental. This is not surprising, because only 10% participated
in research fellowships, of which 79% were 1 year in duration. Thus, the suggestion
of the Lenfant report is demonstrated within our specialty.5
Consistent with our results, the survey by Nadol3
showed that 13% of the young otolaryngology faculty members surveyed had NIH
funding, and they devoted only 13% of their time to research, which contrasts
with the specialty of internal medicine, in which 50% of a physician's time
is spent conducting research.
In 2000, Smith4 reported findings of
a survey of academic chairpersons; the most frequently recruited faculty members
in the last 5 years were generalists, and generalists were most likely to
be recruited in the future. Interestingly, the program directors listed the
ability to conduct research as a perceived advantage of entering academic
medicine. However, they ranked research as lower in priority than clinical
skills and resident teaching in their decision to hire new faculty. Unfortunately,
this hiring practice will cause a continued decline in the ability of our
specialty to contribute substantially to new knowledge. This will result in
a situation in which other specialties or industry will dictate the advances
in the future care of our patients, and, at best, we will collect groups of
patients and provide research material.
To obtain "protected" time for research, individuals need to be funded,
an endeavor at which our academic clinicians have not been very successful.
Unless there are large endowments, money for research funding comes either
externally or internally from shifts in clinical funds. The medico-economics
of the last few years have made it more difficult to shift funds internally.
Competing successfully for extramural funding requires skills and preliminary
data. The skills needed to conduct research are acquired only with significant
effort and a significant time commitment. One half day per week hardly seems
sufficient protected time for research. Furthermore, why should 4 months of
research during otolaryngology training produce an investigator, when it requires
5 years to train a clinician and surgeon? Is learning the scientific method
a 4-month proposition?
Although we attract the most accomplished medical students to our specialty,
as indicated by their scores on national tests and their high ranking within
their medical school classes, we do not convert them into clinician-investigators.
This could be the result of the mixed message that program directors present
or the lack of curiosity of our trainees. This is particularly distressing
because we are in an exciting time of accelerating discovery. The discovery
process increases the complexity of our scientific methods, requiring increased
training to understand them. The establishment of the National Institute on
Deafness and Other Communication Disorders and the increased money given to
the NIH by Congress show the government's desire to enhance biomedical research
for those who have the skills to make significant contributions.7
Unfortunately, our specialty is not training enough people with these skills.
One strategy to improve the quality and magnitude of our research effort
is to develop 7-year otolaryngology training programs. These programs would
provide the required 5 years of clinical training deemed necessary for becoming
a competent clinical otolaryngologist plus the 2 years of research training
deemed the minimal requirement for a successful research career. These programs
would train clinical investigators to provide quality patient care and would
teach the skills necessary to compete successfully for research funding. However,
only half of our program directors are aware of this option and would recommend
this career option to medical students. How do we interpret this observation?
Is this a lack of understanding of the process needed for training investigators
or the result of simple misinformation?
Our specialty's leadership must accept our current shortfall and look
to the future. We must encourage medical students to understand the need for
clinician-investigators. In addition to efforts by our leadership, the program
directors have to make a special effort to attract the right medical students
and to encourage them to pursue research as part of their training. In the
end, the enthusiasm, motivation, and drive of individuals are the largest
factors affecting research output. Although we cannot generate personal curiosity
and motivation, we can direct students to new pathways and fashion an environment
that allows them the time needed for them to pursue and develop novel ideas.
AUTHOR INFORMATION
Accepted for publication May 17, 2001.
This work was supported in part by grant AI 45583 from the National
Institutes of Health, Bethesda, Md.
Corresponding author and reprints: Robert M. Naclerio, MD, Section
of Otolaryngology–Head and Neck Surgery, University of Chicago, 5841
S Maryland Ave, MC 1035, Chicago, IL 60637 (e-mail: rnacleri{at}surgery.bsd.uchicago.edu).
From the Section of Otolaryngology–Head and Neck Surgery, Pritzker
School of Medicine, University of Chicago, Chicago, Ill.
REFERENCES
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ABSTRACT
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4. Smith RV. Workforce issues for the academic otolaryngologist. Laryngoscope. 2000;110:1602-1606.
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PUBMED
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