The number of neurosurgeons involved in research has been stable or declining over the past two decades despite an increase in the number of practicing physicians and the funds available for biomedical research. Explanations for declining interest in research include an increasing proportion of students and residents with large academic debt, the increased time to prepare for a research career, a perception that research support is difficult to obtain, increased pressures to provide clinical care and inadequate time for clinicians to do research projects.
In the last decade, the number of residents in neurosurgery training has been stable with top quality candidates entering the subspecialty. The opportunity to obtain research training for our “best and brightest” during residency, however, has been threatened by several recent developments. First, nearly a quarter of training program directors believe that research does not belong in training programs, according to a survey conducted in 1998 by the Society of Neurological Surgeons.1 Second, reluctance to pursue research training is related to reduced funding for non-clinical time in training (a problem related to HCFA funding for Graduate Medical Education). Third, surgeons are urged to increase patient volume in most academic centers simply to pay the bills.
A more subtle threat to research training during residency is the tendency to substitute clinical specialty training for research training. Folding fellowship training into the traditional training program was approved by the American Board of Neurological Surgery to encourage subspecialty growth without approving subspecialty Board certification. Thus the ABNS is willing to subordinate research training for clinical training in the subspecialties of neurosurgery.
ABNS certification requirements provide a significant obstacle for research after training. All surgeons believe that it is essential to continue an active surgical practice to maintain skills and to pass the certification examinations. This problem, unique to surgeons, makes it difficult to commit to research after training.
Grant Programs Adjusted
In past years, the problem for neurosurgeons who want to do research after residency was exemplified by the National Institutes of Health’s K08 Award, designed for mentored research after training. The award required an 80 percent commitment of professional effort to research and no more than 20 percent dedicated to clinical activity for five years. This time allocation was a clear deterrent for surgeons who wanted to pursue a research career.
The NINDS recognizes the problem and seeks more neurosurgeons who are in training or recently completed training to pursue research as part of their academic life, to enhance research relevant to our specialty, to increase the translational aspects of research and to stimulate a return to academic pursuits within all training programs.
Director Gerald Fischbach, MD, appointed a subcommittee of the NINDS Advisory Council a year ago to develop a plan to accommodate research by neurosurgeons and neurologists during their training years and soon afterward. (Robert Martuza, MD, and myself were the neurosurgery representatives on that committee). Grant programs already in existence were adjusted to resolve the problems noted above. Those programs designed for medical students were made more user friendly, including 1) suspension of loan interest payments during research training, 2) funds for travel, cost of living, supplies, etc. and 3) training for one or two years during medical school or immediately afterward.
Residents in training and surgeons who recently have finished training are included in the revision process. The new KO8a Award features competitive salaries eliminating the need for departmental subsidies, more funding for supplies, suspension of loan interest during the research years and reduced time required for research training for neurosurgeons (50 percent each for research andclinical activity). Better access to awards (such as the RO1) is also part of the plan. For those who are successful in research during training and progress from a KO8a Award to the RO1 award, payment of loan principle as well as interest suspension will be made available during the period of the award. These revised programs likely will be made available in 2001.
It should be noted that the NINDS budget has grown 15 percent annually over the past two years, with an anticipated increase of 15 percent during the coming fiscal year. It is hoped that Congress will continue to support biomedical research fulfilling its promise to double research funding over six years, commencing in fiscal year 1998. We are halfway there. There is a bright light at the end of the research tunnel. There couldn’t be a better time for neurosurgeons to apply for grants from NIH.
Julian T. Hoff, MD, is Chair of the AANS Neurosurgery Research and Education Foundation and AANS liaison to the National Institutes of Health.