The growing crisis in academic medicine is a threat to medical research
“If you have any good leads on a job let me know.”
Those words are unnerving coming from a respected physician scientist who I had just asked to serve as a reference for my own career search. His comment spoke to a pressing concern. He had eminent credentials and was exploring intriguing scientific questions but was struggling to find funding. If the trend continued he may be forced to close down his lab, displacing not only him but also his research assistants and aborting years of scientific effort.
This experience is playing out regularly across the country. We do not typically think of physicians struggling to find gainful employment, but this is exactly what is happening. Generations of young and mid-career physician researchers are struggling to find academic positions. Those who do have established appointments often do not have the time and money to actually perform experiments.
A few trends have made this problem worse in recent years.
Hyper-competitive grant making and tight labor markets have created unsustainable working conditions in academic medicine. It used to be that advanced training guaranteed an academic position, if not tenure. Now this applies only to a minority of researchers. Simply put, there are more advanced medical graduates and researchers than there are positions. To some degree, this trend mirrors what is happening in academia as a whole, including the humanities. But the popular conception that science and technology fields are increasing in prominence in our society has masked the urgency of this research crisis.
At the same time, funding for research hasn’t kept pace. After adjusting for inflation, funding from the National Institutes of Health has actually declined since 2003. In 2015, a team published in JAMA a detailed economic analysis of the state of medical research in the United States. Their statistics portrayed a gripping tale of national decline: the rate of growth of national investment in medical research decreased to 0.8 percent per year for the years 2004-2012, down from 6 percent annually between 1994-2004. Only 0.3 percent of all research dollars were spent investigating methods to make health care more effective and efficient. And America's share of global research funding decreased from 57 percent to 44 percent. Perhaps most telling, in per capita work force size in biomedicine the U.S. ranked squarely in the middle of the pack, below countries such as France, Spain, the UK, Canada, Germany, China and Korea.
Academic medical centers themselves bear some responsibility. In response to stricter performance requirements and alternative payment models, hospitals are taking on more financial risk and facing shrinking profit margins. Battles with health plans, shrinking philanthropic support, and pressures to consolidate have shifted the financial landscape for many academic medical centers. Such centers have historically operated on razor thin margins, and those margins have only grown tighter in recent years.
As a result, these research centers have adopted the lexicon of finance and efficiency. Physicians now hear about cost cutting, efficiency, and relative value units (RVUs are a measure of clinician productivity). All of this can serve a valuable role, but not when it threatens the scholarly ethos of the institutions themselves. Tenure track positions are increasingly rare, time shielded from administrative and clinical obligations is diminishing, and funding support for faculty is eroding.
Institutions are finding other ways to save money as well. The increasing prevalence of "soft money" in professor salaries is troublesome. Academic medical centers are dropping direct financial support for their faculty members and indirectly reimbursing them via federal grants that researchers obtain. In essence, researchers have to pay their own way. New capital campaigns, recruitment of star faculty, and publicity over NIH funding levels are still common in academia. However, these priorities often come at the expense of young clinician researchers and post doctoral students who are disproportionately at a disadvantage in obtaining federal grants.
Research is a long-term initiative. It operates in cycles of months to years, and does not immediately deliver a return on investment. It is labor intensive and costly. But to evaluate these expenses solely through the lens of line items and balance sheets would be myopic at best. The spirit of discovery and the pursuit of treatments for disease is our calling as researchers, and it ought not be jettisoned in the face of tighter budgets.
All of this is coming at a difficult time for medical research. Trump proposed almost a 20 percent cut to the budget of the NIH — the largest reduction in the modern era. Their effects would be nothing less than catastrophic. It would imperil clinical care and gut many research programs. Many of young scientists would be shortchanged out of an academic career. Those with multi-year grants may suddenly find themselves without financial support in the middle of their projects. Efforts to find novel treatments, such as President Obama’s 21st Century Cures Act, would be overturned. And a large engine for country’s economic vitality would be derailed.
Ultimately, physicians and scientists must take ownership for their own role in this problem. Biomedical researchers have been prominent beneficiaries of the generous largesse of the American public for the last 70 years. There have been dramatic advances in medicine during this time but our inability or unwillingness to communicate the value of our work as a field has contributed to the crisis in academia.
There are a few bright spots. The recent March for Science represents the strongest public support for scientific inquiry since the space race in the 1960s. President Trump’s initial NIH budget cuts were overturned by a last minute increase in Congressional appropriations prompted by public advocacy. While a recent point system to introduce more equity in NIH grants failed, director Dr. Francis Collins had communicated the need to better support early stage investigators.
Fortunately, my own job search ended well and the imperiled investigator I quoted earlier is still conducting his research. I am deeply grateful to have found a place at a leading academic medical center. But others have not been so lucky. There are thousands of desperate scientists attempting to make real, valuable contributions to our understanding of disease but are struggling for time, funding, and mentorship. For those of us trying to push medicine forward, these can be perilous times.
Dr. Rusha Modi is a faculty member at the USC Gehr Center for Implementation Science, where he focuses on ways to improve the quality of health care.