The capacity to produce and apply new knowledge is integral to creating successful economies and healthy communities. This critically depends on a research ecosystem that is well-funded, organized, and balanced. Nevertheless, the recent Fundamental Review of Science led by Dr. David Naylor (aka the ‘Naylor Report’) indicates that measures of all three elements have significantly eroded in Canada when compared to its international peers. As members of the Clinician-Investigator Trainee Association of Canada (CITAC), we represent students completing dual training in science and medicine, and are part of a larger community that specializes in bridging the gap between the bench and bedside. Our ability to participate in the mission to improve the health of Canadians is inextricably linked to the vitality of the broader research community. In this context, the current funding climate leaves little room for optimism for the future of Canada’s research enterprise and our place within it. We therefore respectfully call on the Government of Canada to implement the Recommendations of the Naylor Report in their entirety and highlight the key points that particularly resonate with us.

 

First, we fully endorse the Report’s recommendation that support for trainees needs massive reinvestment and reorganization to reflect the current realities of scientific training. Today, students spend more time completing their degrees, engage in longer post-doctoral studies and take on more debt. This issue is compounded for Clinician-Scientist trainees, who will also complete MD degrees and residency programs. Despite these realities, funding for student awards has effectively decreased due to inflation, and the duration and value of awards has not changed. We particularly encourage that the value of awards be harmonized across councils and remain competitive in value to attract top students that would otherwise choose to study elsewhere or enter another field.

 

Second, we are concerned to learn that Canada is the only G7 country to decrease spending on research as a proportion of the gross domestic product (GDP) over the last 15 years. Currently, Canada spends an astonishing 32% less than the OECD average, rapidly falling behind key East Asian countries and several similarly-sized economies. This is associated with severe underfunding of research infrastructure – half that of most other countries – which compromises the mission to turn scientific discoveries into medical advances, a key area in which Clinician-Investigators operate. To compound this issue, Canada’s universities are making up for the shortfall by increasing tuition and class sizes, the revenue from which is being increasingly used to fund research. Put best in the Report on p. 149, “universities are using dollars designated for the teaching mission to underwrite the research mission”. As students receiving training at these institutions, we find this highly disconcerting. At a time in which our society must find solutions to adapt to changing demographics, disruptive technologies, and the growing burden of chronic disease, the gradual retreat of the Government of Canada from research is deeply unsettling.

 

Third, we find the Report describes a worrying lack of coordination and coherence in Canada’s research ecosystem. In the increasingly interconnected world of research, multidisciplinary work and the ability to foster interprovincial and international links is rapidly becoming a key determinant of productivity. As clinician-investigator trainees, whose research spans the gamut of disciplines from basic biology, to engineering, health services, population health, and humanities, we welcome the Report’s recommendations to improve the harmonization of Canada’s research agencies by the creation of the National Advisory Council on Research and Innovation to work together with Canada’s Chief Science Advisor. We commend the Government of Canada of taking the first step to making this a reality by appointing Dr. Mona Nemer as the first Chief Science Advisor on September 26, 2017.

 

Lastly, we share in the disappointment expressed by the Report’s authors that independent, investigator-driven research has been slowly but surely eschewed in favor of priority-driven programs. We are in full agreement with the Report about the intrinsic value of fundamental, curiosity-driven research. While its short-term payoff is unpredictable, basic research invariably pays dividends in the long-term, as it has done in the past for Canadian society. For example, the curiosity-driven work by James Till and Ernest McCulloch in the 60s investigating the effects of radiation on cells has given Canada a leading position in stem cell research, yielding major discoveries and spawning multiple international companies. In addition, robust support for independent researchers and their students generates a critical mass of individuals trained to approach problems in creative ways, and contributes to an innovative society.

 

We therefore join the calls of our colleagues in the Canadian research community in calling on the Government of Canada to act of the recommendations of the Report. We are grateful to be part of a nation where so many minds are deeply engaged in scientific inquiry.

 

 

 

Sincerely,

 

The 2016-2017 CITAC Executive Team

 

Kirill Zaslavsky, Josh Abraham, Patrick Steadman, Sara Mirali, Ellen Zhou, Kristen Barton, Matthew Benesch, Peter Liu, Elina Cook, Christophe Moderie, Nicholas Jette, Tina Binesh-Marvasti, Caitlin Lees, Alvin Tieu, Katarina Ondrusova, Andrea Jones

 

 

                                                                                                                                            Written by Patrick Steadman; edited by Ellen Zhou and Kirill Zaslavsky

     During 2016, CITAC members worked hard to establish answers to pressing questions on Canada’s clinician-investigator (CI) training. This hard work continues CITAC’s tradition of conducting research on CI training and publishing this work and is especially relevant following changes to Canada’s support of CI training in 2015 (Webster). CI’s are important to the medical and research community as they are clinicians who spend at least 50% of their time working on essential research. Clinician-scientists are those who spend 80% of their time on research.

     A fundamental question that had remained open in Canada was how successful are MD-PhD programs at training CIs? While in the US, NIH-funded programs report that 66% or more (depending on data source) of their graduates become clinician-scientists (Brass et al., 2010). No similar measures have been compiled for Canada until now. From Zhou et al. (2016), who surveyed all alumni of McGill’s MD-PhD program found that of those that have completed training, 60% had roles defined as clinician-scientists. For its part, University of Toronto’s latest annual report states that 55% of its graduates have become clinician-scientists (found here). CITAC has completed a national survey of graduates from all MD-PhD programs in Canada, which has been accepted in CMAJ Open. To date, 60% of the graduates have become clinician-scientists, and nearly 90% are primary investigators on research grants with 77.8% holding more than one. This data clearly demonstrates that Canadian MD-PhD programs are a vital source of clinician-investigators for our healthcare system.

    The survey also highlighted several areas that facilitate trainee success. For example, a key pillar of training is mentorship by peers and senior CIs. This has been discussed before by CITAC (see Yoon et al., 2013) and examined in detail by Jones et al. (2016), who surveyed MD-PhD program directors and trainees on program structure, funding, and integration of research and clinical training available within their institutions. Surprisingly, we found that more than half of all programs did not have formal mentorship opportunities, a serious barrier to trainee success. Furthermore, stipend amount and tuition varied, especially when students were in the MD portion of their training. Such variability in trainee support, coupled with limited mentorship opportunities, may compromise the success of training programs in generating CIs. CITAC strongly believes that MD-PhD training programs would benefit from sharing practices and data on how individual program structures meet their trainee needs. A key goal for CITAC this year is to improve communication across member institutions and between trainees and program leadership. This nationwide collaboration can help increase opportunities for mentorship, career development opportunities and help inform design of best practices for training clinician-scientists.

    CITAC also examined the role of non-governmental organizations (NGOs) for promoting research in medical students (Manoranjan et al., 2017). By collaborating with the Mach-Gaensslen Foundation, CITAC analysed data on the 621 Canadian medical student research projects sponsored since 2005. Using pre- and post-research questionnaires and 5 and 10-year follow-up they found 96% of students would recommend a similar experience to other medical students and similarly that it was of great value to their medical training. At 10 years following the experience, 41.67% of respondents were physicians with a research component in their career and 58% held faculty appointments at a medical school. It is unclear whether these students would have become clinician researchers without the experience, but within this cohort participants report the experience as being impactful.

    Taken together, our work over the past year highlights the importance of supporting and expanding clinician-investigator training capacity in Canada. Though dwindling in proportion to the overall number of medical graduates, clinician-investigators remain a vital national resource that is fundamental to continued integration of medicine with research. In 2017, CITAC will continue to advocate for addressing trainee needs and increasing the viability of the clinician-investigator career pathway by encouraging nationwide collaboration across training programs and stakeholders.

 

References:

1. Brass, L. F., Akabas, M. H., Burnley, L. D., Engman, D. M., Wiley, C. A., & Andersen, O. S. (2010). Are MD-PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD-PhD programs. Academic Medicine : Journal of the Association of American Medical Colleges, 85(4), 692–701. http://doi.org/10.1097/ACM.0b013e3181d3ca17

2. Jones, A. A., Ng, E., Deguise, M.-O., Mak, L., Ouyang, B., Sivapragasam, M., et al. (2016). MD/PhD Training in Canada: Results from a national trainee and program director review. Clinical and Investigative Medicine …, 39(4), E132–9.

3. Manoranjan, B., Dey, A. K., Wang, X., Kuzyk, A., Petticrew, K., Carruthers, C., & Arnold, I. (2017). Role of non-government organizations in engaging medical students in research. Journal of Investigative Medicine : the Official Publication of the American Federation for Clinical Research, 65(3), 709–716. http://doi.org/10.1136/jim-2016-000348

4. Webster, P. C. (2015). CIHR cutting MD/PhD training program. Canadian Medical Association Journal, 187(12), E381–2. http://doi.org/10.1503/cmaj.109-5124

5. Yoon, J.-Y., Appleton, T., Cecchini, M. J., Correa, R. J., Ram, V. D., Wang, X., et al. (2013). It begins with the right supervisor: Importance of mentorship and clinician-investigator trainee satisfaction levels in Canada. Clinical and Investigative Medicine , 36(6), 269–276.

6. Zhou, T. E., Savage, P. A., & Eisenberg, M. J. (2016). Canadian M.D.-Ph.D. Programs Produce Impactful Physician-Scientists: The McGill Experience. Journal of Biomedical Education, 2016(4), 1–4. http://doi.org/10.1155/2016/3836467

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