About a week ago, Tim Kreider wrote an excellent post about the differences between medical

school training and scientific training. As the only other denizen of Science-Based Medicine who
has experienced both worlds, that of a PhD and that of an MD, and as the one who two decades
further along the path than Tim (give or take a couple of years), his musings reminded me of
similar musings Ive had over the years, as well as emphasizing yet again something Ive said
time and time again: Most physicians are not scientists. They are not trained like scientists; they
are trained to apply scientific knowledge to the care of their patients. Thats what science-based
medicine is, after all, applying science to the care of patients. Not dogma. Not tradition. Not
knowledge of antiquity. Science.
Leave dogma, tradition, and ancient knowledge to practitioners of alternative medicine.
Thats where they all belong. Whether you want to call it alternative medicine,
complementary and alternative medicine (CAM), or integrative medicine (IM), it rarely
changes and almost never abandons therapies that science finds to be no better than placebo,
whereas scientific medicine is, as it should be, ever changing, ever improving. Ill grant you that
the process is often messy. There are often false starts and blind alleys, and physicians are all too
often reluctant to change their practices in response to the latest scientific findings. We
sometimes even joke that for some practices, it takes the supplanting of one generation of
physicians with a new generation to get rid of some practices. But change does come when the
science and evidence are there. Indeed, for example, in response to evidence that a bacterium, H.
pylori, causes duodenal ulcers, medical practice changed in a mere decade, which is about as fast
as anyone could do the science and clinical trials to show the validity of the new concept.
Although CAM practitioners like to hold up the example of Barry Marshall and Robin Warren,
the researchers who discovered that H. pylori causes most duodenal ulcers, as an example of how
researchers with radical ideas are ostracized, but that story is largely a myth, as our very own
Kim Atwood showed.
The application of science to medicine is a difficult thing. It takes basic scientists and clinicians,
but the two of them exist in different worlds. Or so it often seems. Thats why some individuals
seek to straddle both worlds. Tim is one such person. So am I. Unfortunately, most people dont
understand what we do very well. We wear two hats. In my case, Im a surgeon, and Im a
scientist. In Tims case, hes a scientist and a physician, but he doesnt yet know what kind of
physician he will end up being. At the risk of sounding somewhat arrogant, I believe that we, and
others like us, represent an important element in bridging the gap between basic science and
clinical science, in, essentially, building a more science-based medicine.
By saying that people dont understand very well what clinician-scientists doI dont mean that
people dont understand what it is that a doctor or a surgeon does. Everyone knows that a doctor
takes care of patients and that surgeons operate on patients, after all. I also dont mean that they
dont understand what a basic scientist does, although most of them do seem to have some sort of
an odd picture of us in a lab with test tubes and brightly colored solutions bubbling in the

background, the same misconception that is common about pure basic scientists. In fact, I would
go so far as to say that even most doctors and most basic scientists probably dont understand the
difficulties of combining a clinical career with laboratory research, because those of us who try
to do both are in a distinct minority. The vast majority of doctors do only clinical practice, and
basic scientists, not having gone to medical school, will never have the responsibility of caring
for patients. Even among the minority of doctors who actually do research, the majority do
mainly clinical research (testing new therapies in clinical trials, for example), and that is what
most people think of when they think of doctors doing research.
Combining a laboratory research career with a clinical career has always been difficult, but these
days its become a Herculean challenge. One aspect of biomedical research not understood by
most lay people is that basic scientists in academia doing research are usually expected to pay
much (usually at least 50%) of their own salaries and all of their laboratory overhead through
grant support, preferably from the NIH through the gold standard grant known as an R01. In
smaller colleges, there are often faculty whose primary responsibility is to teach, but the big
universities tend to require research and grant funding to support that research. If young faculty
members dont demonstrate the ability to compete for such grant support, they dont get tenure.
Usually, upon being hired fresh out of their postdoctoral fellwoship, they are given a startup
package with enough support to keep their lab going for perhaps three or four years. After that,
they are expected to be able to fund their own laboratories entirely through external funds. The
bottom line is: If they cant achieve that in the time allotted, they dont get tenure, and often
when they fail to get tenure they are shown the door. Its a very Darwinian system. Yes, there are
other requirements for tenure, such as peer-reviewed scientific publications of sufficient number
and quality, science good enough to win the respect of peers, and evidence of teaching talent, but
the bottom line is: If you cant attract enough funding, the other stuff will hardly be considered.
Now, consider the clinician-scientist. We have to compete for grant money with the same hungry
basic scientists who can spend the vast majority of their time doing research. Worse, most of the
reviewers in the study sections that decide which grant applications get funded are basic
scientists. Yet, a large proportion of our time is taken up caring for patients. Those of us who
have not undergone formal Ph.D. training may not have adequate experience in formulating a
research plan in a logical and compelling narrative that can convince a study section that (1) we
have a reasonable hypothesis; (2) we have evidence to support the hypothesis; and (3) we can
formulate a scientifically credible plan to study that hypothesis. And we have to do this while
devoting a significant part of our time to patient care. I am fortunate enough as a clinicianscientist in that I have a position where I can spend more time in the lab and office than I do
taking care of patients, but my patient care responsibilities are still something that take up a lot of
time. Consequently, some basic scientists look at doctors (especially surgeons) with
condescension. (Oh, isnt that precious! Hes trying to do serious research!) Unfortunately,
occasionally, that condescension is deservedbut it is not deserved nearly as often as some basic
scientists seem to think it is.

There was a time twenty or thirty years ago when clinician-scientists could be supported by
slush funds derived from the clinical income of the department in which they worked. This
was especially true of surgery departments, which were often revenue machines. Those days are
long gone, dead and buried. Academic medical centers now have to live in the same world as
private hospitals from a financial standpoint, and managed care companies are not willing to pay
them more, even with the increased overhead and inefficiencies that come from training medical
students and residents. True, Medicare does pay academic medical centers a per-head sum for
such training, but that only covers direct costs. It doesnt cover the hidden costs that come from
the infrastructure that it takes to train residents and the inefficiencies that training residents
involve. For instance, most surgeons could get a lot more operations done in a week if they
didnt have to carefully and slowly take residents through them. That would mean more revenue.
But we academic surgeons have made a conscious decision that we believe that training the next
generation of surgeons is of the utmost importance, and we derive many rewards from it. For
example, theres nothing like seeing a trainee achieve success. It reflects back on everyone who
trained him or her.
Be that as it may, between decreased reimbursement and the increased expenses involved
running an academic department, there is often little or nothing left over for research after paying
the billsif the department is lucky enough and well-managed enough not to be in the hole. In
fact, academic physicians are generally expected to bring in enough clinical revenue to cover
their own salary and expenses. Given that the actual collection rate for what is billed may be only
$0.25 to $0.40 on the dollar (or even less), for a surgeon, covering ones own salary, ones
secretarys salary and overhead, office overhead (yes, the University charges office rent), and
other expenses can require billing for as much as $500,000 to $1 million a yearor even more.
Busy clinicians can pull this off. Part-time clinicians dont have a prayer, particularly if they have
the added overhead of a laboratory. That means, to support clinician-scientists, an academic
department must explicitly make the commitment to support research in a bit of an almost
communistic endoavor. Busy clinicians in the department must buy into the vision and be
willing to subsidize the development of new physician-scientists with some of the fruits of their
own clinical productivity, accepting, in essence, less income than they could make otherwise in
return for the benefits of belonging to an academic department and practicing at an academic
medical center. That is, in essence, the compact. The other part of the compact is that physicianscientists usually end up accepting considerably less salary than they could make in private
practice (or even if they were a busy academic clinician) in order to have enough protected time
to do their research. This is not an inconsiderable hurdle for a new clinician-scientist to face in
these days of medical students finishing with a quarter of a million dollars of student loan debt,
which is why MD/PhD programs funded by the NIH are so important.
But what about grant support? That can help, but a scientist can only ask for salary support for
the percentage of his time that is devoted to the research project for which grant support is being
requested. Consequently, if you are 50% clinical, there is no way you can ever support your

entire salary, as basic scientists can, with grants. The most you can ever hope to support is 50%.
Rare clinician-scientists can support maybe 70% of their salary if they are (1) only 30% clinical
and (2) good enough at getting funded to fund the 70% effort they are putting towards research.
Its worse than that, though. Most clinicians make an academic base salary, plus a salary that
comes from clinical revenue generated by the department. Grant support can only ever be
applied to the academic base salary. Consequently, clinicians can rarely cover more than 20-40%
of their total salary with grant support. Again, even with an NIH grant, almost no clinicianscientist can cover his own overhead through clinical activity and grant support, even very
successful ones. It would take several hundreds of thousands of dollars a year in government
grant support, which includes around 50% or so added to the grant for institutional overhead, to
have a shot at doing it. The benefits physician-scientists bring to the department are usually not
financial; rather they include intellectual benefits and the prestige that an active and successful
research program brings. Again, not all departments can afford such benefits in this climate of
diminishing reimbursement.
Of course, as clinician-scientists, we do have one advantage over basic scientists in one area. We
understand the clinical management of the disease were studying in an up-close and personal
way that the basic scientist can never match because they dont take care of patients. We deal
with patients with the disease and watch the course of the disease every day. We know the
deficiencies in present therapies and issues needing more research attention in a way that basic
scientists have a very hard time matching. We make observations about the disease that basic
scientists have an even harder time making. Indeed, the flip side of the condescension basic
scientists all too often heap upon clinicians trying to do basic and translational research is the
similar condescension far too many clinicians heap upon the way basic scientists tend to focus on
molecular and cellular mechanisms rather than practical results. We want new therapies now
because patients are suffering and dying now, and are often impatient with the leisurely pace (or
leisurely it seems to us) at which pure science basic scientists move. This is not an insignificant
factor, given the reorientation of the NIH in recent years towards research that is likely to lead to
treatments sooner rather than later. Nonetheless, overall, the forces arrayed against the success of
clinician-scientists are formidable indeed, and bridging the differences between the cultures of
basic scientists and pure clinicians is not the least of them.
Perhaps the most formidable challenge for a clinician-scientist is finding enough protected
time (time with little or no patient care responsibility that is protected for research). One of
the most challenging tasks a young clinician-scientist has is to protect his research time from the
inevitable intrusions of patient care. If he doesnt, then one day he will wake up to realize that he
hasnt been in his laboratory for anything other than brief visits for over a month; that his entire
schedule has been taken over by patient care demands; and that his lab is about to run out of
money because he never had time to oversee the production of enough preliminary data to write
a competitive grant application. Having adequate protected time is impossible unless a young
faculty members chairman understands the need for protected time and is willing to help protect

that research time. Sometimes that means laying down the law that new patients beyond a certain
number will have to be seen by other surgeons. Without the chairmans support, even the best
effort to protect research time will likely fail.
Ive seen it with colleagues and friends over the years. Driven by the unfortunate financial reality
of academic surgery today, their chairmen or division chiefs, while paying lip service to the need
to provide protected time for research, would demand more and more clinical revenue, which
means seeing more and more patients. For a while, the clinician-scientists would try to make up
for steady infiltration of their research time by patient care responsibiliteis by working more and
more late nights and weekends, but eventually something had to give, and almost inevitably it
would. In these cases, what almost always gives is the research. The clinician-scientist
concludes that he is forced to give up research andusuallybecome primarily a clinician.
Sometimes the rare surgeon-scientist with an exceptional devotion to and talent for research will
become a pure basic scientist, but they can only do that if they are so successful at publishing
and applying for grants that their labs are, in essence, awash in grant money. Ive been
extraordinarily fortunate so far in that all my bosses and the institution have done their best to
help me protect my research time, but I have no illusions that, were I ever to lose all my grants
and show no promise of obtaining more, my current institution (or any institution) would cut me
slack for very long.
In some ways, I think that surgeons trying to do research have it worst of all. In the medical
specialties, it is often possible to arrange schedules so that doctors doing research only have
concentrated clinical duties one or two months out of the year, with the rest of the year serving as
protected time. In medicine, pediatrics, and other specialties, this is known as being on service
and usually involves being the attending who is responsible for an inpatient service for the
month. Once the months up, the inpatient clinical responsibilies end, leaving only however
much outpatient clinical responsibility was agreed to. For busy clinicians, this can be a lot of
outpatient responsibility, but for clinician-scientists, it is often designed to be only one day of
clinic a week or even less.
In surgery, such huge chunks of protected time are rarely possible for several reasons (outside of
V.A. or county hospitals, and even there such huge chunks of protected time are rapidly
disappearing). First, surgery is personal. Patients dont want just any surgeon operating on them.
They usually want a specific surgeon that theyve come to trust. Consequently, the clinical
burden is ongoing throughout the year, leading to us trying to protect days at a time, rather than
weeks or months at a time. Second, even if we could arrange our schedules the way medical
doctors do, our specialties are skill- and task-oriented. We would risk the atrophy of our
operative skills if we were only to operate intensively one or two months a year. (Indeed, clinical
surgeons sometimes look down on surgeon-scientists as not having the same level of surgical
skills they do.) Finally, surgeons have a very special relation to their patients. If a patient I
operate on has a postoperative complication, Im going to take care of it, unless for some reason

Im on vacation or out of town (and for some surgeons, even those are not always barriers to
taking care of their own). It doesnt matter if Im on call or not, if its the middle of the night or
not, or if its during the weekend or not. Thats just the nature of surgery as a specialty. Although
my surgical specialty has relatively few emergencies, for other surgical specialties (for instance,
GI surgery), just this aspect of surgery alone can make a productive research career extremely
problematic. The bottom line is that we are expected to be just as good as surgeons who are pure
clinicians while devoting only part of our time to surgery and just as good at laboratory research
as basic scientistsagain, while dedicating only part of our time to it, usually a lot less than basic
scientists can. We rarely succeed at both to an equal degree.
I realize that basic scientists will retort that they have other responsibilities, too. They teach,
sometimes a lot. They sit on committees. They have bureacratic responsibilities that take them
away from their research every bit as much as surgery. Well, not quite. If a basic scientist fails to
fulfill his teaching or administrative duties or doesnt fulfill them well, no one is likely to die or
to suffer a complication or additional pain. Patient care often cant be put off, at least not for
long. Unlike teaching, it cant always be predicted or scheduled. Thats the difference. Its
possible to succeed as basic science faculty while being not so good at other responsibilities, like
teaching. My own experience with several professors during graduate school bears this
observation out. There were a few professors who were highly successful in their research, with
many publications, international reputations, and oodles of grant money. Unfortunately, some of
them were awful in the classroom. There were even more faculty who were just OK in the
classroom, butagainran successful laboratories.
I realize that what I said may sound arrogant to some or as though I am denigrating the
difficulties basic science faculty face. I assure you that it is not and I am not. Not having much
experience in teaching classes, I would probably have an absolutely hellacious time at first
learning to become a competent classroom teacher (as opposed to a clinical teacher, which is
different) if I ever tried to be straight basic science faculty. However, its just the nature of the
beast. You cant afford to be bad or even mediocre as a physician, regardless of whether or not
you are a scientist as well. You just cant. If you are bad or mediocre, you have no business
treating patients. You have to be at least competent as a physician or surgeon, and preferably you
should be excellent. Its also more difficult in a highly technical specialty, like surgery. Practice
makes a difference in highly technical skills, unless you happen to be one of those lucky
surgeons who is just naturally gifted, and, even then, practice is what turns the technically gifted
surgeon into a superstar.
Maintaining ones medical and surgical skills as a part-time physician is perhaps the most
difficult challenge facing the surgeon-scientist or the clinician-scientist. The only way many of
us manage it is to focus their clinical practice like a laser very tightly on one specialized area that
interests us and about which were passionate, which is what I have done. Thats the practicality
of it. The necessity for competence when you dont get as much experience and practice as a

straight clinical surgeon almost always mandates focus. Even then, it remains really difficult. As
a part-time surgeon, I dont do nearly as many cases as a full-time surgeon does, and, as long as I
continue to run a lab, I never will. That is another reason by my practice has to be tightly focused
if I want to do right by my patients and still have the opportunity to do research.
It cuts both ways, too, although thats usually less of a consideration compared to the basic
science faculty with significant teaching responsibilities. Im in essence a part-time scientist as
well. I cant devote the same amount of time to writing grants, papers, supervising the lab, or
even doing experiments that most basic science faculty can and do. There just isnt time. But
perhaps the biggest issue that cuts both ways is the literature. In essence, physician-scientists
have twice as much scientific/medical literature to deal try to keep up with. We have to keep up
with the medical literature involving our specialties and the scientific literature involving our
research, and we have less time to do it, to boot. No wonder I never feel as though Im on top of
the surgical literature. No wonder every so often I get blindsided by a paper related to my
research that I never noticed, probably more so than basic scinetists do. Thats why another
essential practical necessity for success is to have good people working for you and good
collaborators working with you. Although this is true for any researcher, for clinician-scientists
its doubly true: One bad hire can destroy your labs productivity and even ultimately your lab.
You need people who can work with little supervision, and you need collaborators who can help
you out with the more arcane basic science that you arent trained in. In return, you offer your
collaborators your clinical understanding of the disease process and, if you happen to be a
surgeon, one of the most precious resources of all for biomedical research: access to human
tissues.
Finally, perhaps the key difference between being a basic scientist and a clinician-scientist is
predictability. The basic scientist, even the one who has significant teaching responsibilities that
take up a big chunk of his schedule, has a much more predictable schedule. Patient care can be
made somewhat predictable, but emergencies will always occur, the number and frequency of
which depend upon the specific specialty. There will always be calls on weekends or in the
middle of the night. Disease doesnt respect weekends or nights. Moreover, the natural tendency
is for patient care responsibilities to grow slowly and inexorably. In essence, a surgeon can be a
victim of his own clinical success, and his success in the clinical realm can negatively impact
success in the scientific realm. I know one surgeon who has become so popular that every time
he tries to cut back his practice in order to engage in more academic purusits, there is a backlash
from his referring physicians, who start calling him to ask him if he can make an exception just
this one time for this patient or that.
The answer is always yes.
Lets look at a few real-life scenarios that illustrate the conflict between doing bench research
and taking care of patients. Scenario number one: You are in the middle of a big experiment

when the E.R. calls about a patient you recently operated on, who has returned intrabdominal
sepsis. It turns out that your anastomosis has broken down, and the patient needs urgent surgery
to fix the problem. However, if you take off to do the surgery, your experiment will be ruined,
wasting days of work and hundreds of dollars worth of reagents. The choice is really no choice at
all; you must take care of the patient and trash your experiment. You could ask one of your
partners to deal with the complication, but they have patients of their own to deal with. Theyre
all either in clinic or in the operating room, anyway. Besides, its your patients complication.
You need to deal with it, because thats how surgeons roll.
Scenario number two: You have a grant due in a few days. You thought you had planned well,
having canceled your clinic for that week several months prior and told the schedulers not to
schedule any operations that week, in order to allow maximal time to finish the grant. However,
there is a patient that your boss tells you that you must see and take care of now. Alternatively,
one of your top referring physicians is asking you to see this patient as soon as possible. One
more variation: The patient is a V.I.P. that the CEO of your hospital is asking you to see.
Scenario number three (perhaps the most common scenario): Your clinical load has been slowly
growing. Almost without your realizing it, you now find yourself spending less and less time in
the laboratory doing experiments until you are no longer doing benchwork at all. This alone
would not necessarily be a problem. After all, many senior basic science faculty find themselves
no longer doing actual benchwork. (Indeed, in a lab I worked at a long time ago, wed go out of
our way to dissuade our PI from venturing into the lab.) However, over time, your patient load
continues to increase and you now find yourself spending less and less time even meeting with
your lab personnel. You find that you are no longer even sure of what is going on in your lab on a
day-to-day basis anymore. There are a pile of manuscripts that need to be finished, but you cant
get to them because youre always in the clinic or in the O.R.. You try to work on them at home,
but your wife and children demand their fair share of your attention when you manage to make it
home for a while. Youll soon be due to try to renew your grant, something you have no idea if
youll be able to do now. You could try to cut back on your clinic time, but that would mean that
patients waiting time to be seen would increase. Patients with cancer would be forced to wait
longer. Also, if you cut back your clinical productivity, your department would not like it,
because you would no longer be supporting your salary and overhead with clinical revenue, and
this doesnt even take into account the consideration that your referring physicians will not be
pleased.
These are just a few examples, but in the end the conflicts all come down to the tension between
two worlds which are very different, the world of the scientist and the world of the clinician. The
world of the scientist values inquisitiveness and intellectually stimulation. It also tends to be less
interested in practicality and more interested in intellectual pursuits and scientific novelty; i.e.,
answering questions that have never been asked or answered before. In constrast, the world of
the clinician is almost purely practical. It tends to be task- and action-oriented, and protocol-

driven. Asking and answering questions are valued, but only insofar as the questions and answers
pertain to diagnosing and treating disease or overcoming problems that get in the way of good
patient care. The clinician-scientist tries to bridge the gap between these two world in an
increasingly difficult environment.
I hope I didnt scare Tim off; so Ill try to finish on a note of hope. Why do I continue to do it?
Ive often joked that, as an MD and a PhD, I catch equal crap from both worlds. Clinicians
wonder if I know what Im doing in the operating room, and basic scientists dont think I can
hack it as a basic scientist. So why put up with the stress of wearing two hats? Why not pick one
or the other? There are two reasons. First, I think that clinician-scientists bring a unique
perspective to the study of human disease that neither a clinician or a scientist alone can. Second,
as I suspect must be the case with Tim, I want to make a difference. Nothing would be as
satisfying as making a clinical observation, taking it to the laboratory, developing a treatment
based on my laboratory observations, and then testing that in patients and seeing it work. True, I
may never manage shepherd a treatment through all those stages (clinical observation, laboratory
observations on the basic science, development of a therapy based on the science, and testing in
clinical trials). After all, it can take a decade or more to do so, and I probably dont have more
than maybe two decades left in my career, but wouldnt it be great if, before its time for me to
retire, I manage to pull it off?