Physician–scientists are at the crux of medical research, so what are the pathways available for those wanting to make a career combining both the lab and the clinic?
While his colleagues have been honing their surgical skills in operating theatres around the country, Dr Arjun Iyer has chosen a different route.
The cardiothoracic surgical trainee has taken a pay cut and instead spent large chunks of the past three years making models with milk bottles and carefully assessing pig hearts.
At the end of the year he plans to submit his PhD thesis and return to full-time training, but before he receives his surgical qualification in four years’ time, the research he has done may well have shifted the parameters for heart transplants here and around the world.
“I’ve been very lucky I’ve been given this opportunity”, Dr Iyer tells the MJA.
“I see it as an investment in both doing some cutting-edge research that’s going to lead to better patient care and getting an opportunity to become better with my hands and a more skilled surgeon.”
Dr Iyer is a University of New South Wales doctoral student at the Victor Chang Cardiac Research Institute which is affiliated with St Vincent’s Hospital.
Each week he does two days’ clinical theatre work under the guidance of some of the country’s top heart surgeons, including his supervisors Professor Peter Macdonald and Dr Kumud Dhital.
At other times he is investigating how to increase the viability for transplantation of hearts donated after cardiac death.
This work has the potential to increase the number of hearts available for transplantation by up to 20 per cent and is where his hitherto unknown model-making skills have come in handy.
The experience has given Dr Iyer great enthusiasm for research and the possibility of combining it with future work as a consultant.
Researcher–clinicians were once central to medical research in Australia.
In the past, they’ve been the source of many valuable medical research hypotheses, including the initial observation by Melbourne psychiatrist Dr John Cade that the use of lithium was effective in the treatment of bipolar disorder.
But the final report from the federal Strategic Review of Health and Medical Research led by Simon McKeon, AO, and published in April this year, found the amount of research being done by Australian medical practitioners is diminishing.
The review couldn’t put a figure on the number of doctors now engaged in research but said it was widely agreed that the figure is shrinking.
Among other factors, the McKeon review heard that the problem lay with inadequate funding set aside for clinician-directed research, the apparent income disparity between work in the clinic and in the lab, and the lack of a clear career pathway for those wanting to combine the two.
In response, its recommendations include increasing the number of National Health and Medical Research Council (NHMRC) practitioner fellowships to 1000 over 10 years and embedding research training as part of education and accreditation in order to support dual researcher/practitioner education pathways.
The increased number of practitioner fellowships, in particular, could potentially compensate for the extreme difficulty for current part-time researchers to secure NHMRC grants that even full-time researchers only have a 15 per cent chance of receiving.
Dr David Celermajer, the Scandrett Professor of Cardiology at the University of Sydney’s Heart Research Institute, has maintained a combination of research and clinical work since graduating in 1983 and is now one of Australia’s leading medical researchers.
He first described the physician–scientist as an endangered species a decade ago and says many of the same difficulties exist today.
“There are a large group of extremely bright young physicians who are excited by the idea of research, but the opportunities to fulfil that dream are still extremely limited”, Dr Celermajer says.
Nevertheless, while it is more difficult for those wanting to combine the two than it has been in the past, Dr Celermajer and others at the forefront of medical research say the benefits for doctors, patients and our health system of being able to bring clinical experience to medical research, and to put the best and latest medical knowledge to practice in a clinical setting, are huge.
And while the pathway may not be as clear as for other medical careers, it can be rewarding on many levels.
This is particularly so at a time when medical specialties have become so competitive, says another of the country’s pre-eminent medical researchers, Professor Emeritus John Chalmers.
Professor Chalmers’ work on the links between the brain and hypertension over four decades has affected the way patients are treated around the world and he continues to publish up to 30 papers a year.
“Research is hard. You’ve got to keep putting in time and energy and compete for your ideas to bear fruit, to make an impact and to attract funding”, he says.
“It is hard. It is much harder than a constant stream of patients. It’s also much more exciting if it works.”
A research career can commence at any time, says Dr Chalmers. Many begin as Dr Iyer’s has, as part of specialist training and such research qualifications are now necessary in many specialties in order to qualify for top positions in teaching hospitals or senior lectureships.
Selecting the right supervisors and finding mentors working in the field in which you are interested are very important at this stage.
In Dr Iyer’s case, the transplant research he wanted to be part of wasn’t taking place in Adelaide where he began his training at the Royal Adelaide Hospital so he sought the advice of his mentors at the hospital and with their encouragement applied for the position at the Victor Chang Cardiac Research Institute.
Part-time doctoral work is very different to straight training.
Like many, Dr Iyer has had to supplement his original research funding with private philanthropic grants and recently received a $50 000 Avant scholarship.
There may be less money in his bank account, but he says there has been unexpected bonus.
“When you have this research life, although it’s combined with part-time clinical, you do get quite a few weekends off”, he says.
“That’s actually quite nice to go out and enjoy the sunshine, maybe get some vitamin D and go for a run on Saturday morning and go out for dinner.”
For doctors already practising full-time, Dr Chalmers recommends establishing links with a specialty clinic doing research as a way to begin a combined career.
This may involve offering to do half a day each week in an outpatient clinic and joining a research project already underway.
Over the longer term it should be possible to contribute further, offering to draft papers and prepare abstracts.
Dr Chalmers says a part-time masters of public health can provide the epidemiological skills and statistical nous to do further analysis.
Primary care hasn’t had the tradition of combined clinician–researcher roles that have existed in other specialties through academic positions and staff specialist roles in teaching hospitals.
However some of the top schools are now considering making provisions to incorporate higher degrees into general practice registrar training.
Associate Professor at the University of Melbourne, Dr Marie Pirotta spends two days a week in general practice in addition to her roles in teaching and research. She says the two are inextricably linked and complement each other.
“I see things at work that I think will be great research questions and I learn things in my reading for research or teaching that refresh my clinical work”, Dr Pirotta says.
“I also have an understanding of the problems that come up in general practice — the messy complexities of working in general practice and the challenges of being a GP in a busy environment.
“So when I put on my other hat as a researcher I’m asking GPs to work with me in research projects I’m very sensitive to how hard that is.”
And despite Dr Iyer’s initial apprehension at committing three years to research, with the end of his first research project in sight, he agrees that the benefits for those involved in both patient care and research are great.
“In hindsight I have no regrets whatsoever because I think there’s no point in rushing training”, he says.
“I don’t see it as lost time.”
- Annabel McGilvray