Research Culture and Remuneration

Research is the basis of innovation. Any enterprise that aspires to secure its future needs to invest wisely in research and development. Without such investment, the enterprise will invariably stagnate and allow competitors to take over – and these competitors will eventually push it out of business. Although health care is no exception to the need for ongoing innovation, research, and development, this is easily overlooked in a public health care system such as ours, which tends to shield itself from such market forces. The ongoing fiscal restraint in which our health care system operates – which pre-dates, but is further aggravated by the pandemic – has had a particularly detrimental effect on research. When comparing it to managing the healthcare crisis of the day, all too often research is viewed as optional rather than fundamentally important for our ongoing success.

Over the years a strange culture has developed in Manitoba’s health care system, one which places strict and arbitrary divisions between providing service and investing in ongoing research and innovation. It could be argued that during times of crisis it is appropriate, and indeed necessary, to focus primarily on service delivery to the community. However, academic healthcare institutions such as ours, which are the traditional motors of biomedical research, begin to suffer from a pervasive and progressive atrophy in their innovation platforms and activities. Without these our academic hospitals and clinics cannot stay up to date in a rapidly changing world, and sustain delivery of cutting edge health services to Manitobans.

Thus, in our opinion, there needs to be a profound change in culture. We need to embrace research as an integral part of delivering state of the art healthcare. It is only then that tertiary care institutions such as HSC will be able to sustain their role and function as Shared Health’s flagship provincial “advanced care” center. This will require not only a cultural shift at all levels of administration and the full spectrum of health care professionals, but also that we overcome a complex web of arbitrary and outdated regulations that are widely recognized as major impediments to the conduct of clinical trials and studies, be they investigator driven or industry sponsored. Without such change, the ultimate losers remain our patients who are unable to benefit in a timely fashion from novel – and often the only available – therapeutic options.  

Notwithstanding these structural considerations, most would agree that research is expensive and time consuming. Clinicians and clinician scientists are often uniquely equipped to undertake clinical and translational research, as they effectively straddle the bench to bedside gap. But in order to do this successfully, they need the time to develop their ideas, and to establish logistically viable protocols that are seamlessly integrated with healthcare delivery. How should this research time commitment be remunerated equitably in a fee for service (FFS) system? In our current FFS environment, this is, and will remain, very challenging. The average yearly clinical income of an internist (general and subspecialists combined) is somewhere in the $450k range, and for many it is much higher and may well exceed double that sum. Full time PhD researchers, who compete with clinician researchers at the “big tables”, are remunerated at a fraction of this amount. Should clinicians with a major research commitment be remunerated at the level of their PhD researcher peers who undertake comparable initiatives? Or, alternatively, at the level of their FFS peers? Or somewhere in between?

Many FFS based institutions, including our own Department, are perceived as “buying” protected research time from their faculty, who would otherwise be engaged in lucrative service delivery careers. While this may be well intended, aiming to sustain a vibrant research environment and community, no Department will ever be able to remunerate research time equivalently to the FFS income a physician would be able to generate during the same amount of clinical time. It should also be noted that, as per our universities interpretation of the Canadian Revenue Agency’s rules, overhead funds cannot be used as salary support for physicians that contribute to the overhead, i.e. to pay for protected research time. The issue is further compounded by the large differences in FFS income between various subspecialties. We have tried to tackle this, but it has proven very challenging.

In all cases, FFS income increases with increasing clinical service provided – i.e. the more patients seen in a clinic or on a ward, the more FFS billings and income. We would argue that a similar principle should be applied to research income for clinician-investigators/scientists.  In other words, a researcher who consistently attracts national grant support and publishes in high impact journals should be remunerated incrementally for his/her time compared to one who does not achieve such benchmarks. This would need to acknowledge the vagaries of grant application success, and all dedicated researchers need to have sufficient time to succeed at the “big tables”, often with multiple resubmissions of revised applications. But they need to be in the game, dusting themselves off after a failure and generating a more competitive application. The Department as a whole profits much more from investing its limited research budget into clinician researchers who have this tenacious “phenotype”, and who consistently deliver the best effort and output. In today’s world, this output can actually be measured reasonably objectively with established metrics. Conversely, ongoing investment in researchers who are unlikely to ever be able to meet these benchmarks, irrespective of how much time or effort is given, seems wasting the Department’s scarce research budget.

In this context, it is important to mention the large number of faculty members in our Department who have a clinician-teacher job description. They can be key supporters and facilitators of the research enterprise. In their role as educators who provide mentorship as they deliver state of the art healthcare to their patients, they are also in a position to provide seamless integration of research activities in the context of clinical care delivery. The metrics for this role differ from that of career researchers, and they need to be appropriately acknowledged in publications, promotion, and awards. Unlike their clinician investigator/scientist peers, income generation in the context of service delivery is usually not an issue and they are unlikely to require Departmental support for their supportive research contributions.

We know that we have opened a can of worms with this blog. At this point, we are not presenting solutions, but rather stimulating an important and timely discussion. We are looking forward to hearing your comments – please respond in the blog, so others can read and chime in.

Eberhard L. Renner MD FRCPC FAASLD, Professor and Head – Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba

Hani El-Gabalawy, MD FRCPS FCAHS, Professor of Medicine and Immunology Associate Head – Research, Department of Internal Medicine, Endowed Rheumatology Research Chair, University of Manitoba

4 thoughts on “Research Culture and Remuneration”

  1. I always welcome a discussion about how to optimize the research endeavour. Discussions about remuneration for physician conducted research is moot when the culture of Shared Health and the past culture of HSC has been to stymie research as much as possible. To them research is an obstruction to the conduct of clinical care. Even the HSC Foundation has been committed to buying clinical tools rather than supporting research endeavours Our health care leaders need to be educated as to the value of research in providing clinical care. While Ryan Zarychanski published two NEJM papers which heightens his academic cache they were also practical interventions that impact on clinical care
    As you have pointed out or perhaps didn’t point out but I am reinforcing here, our Department is primarily comprised of clinicians providing clinical care and teaching. With the concentration of health care primarily at three hospitals and with Winnipeg being a central hub for all provincial care we have the ability for every clinician to become a researcher or research contributor. There is an endless array of obvious clinical questions presenting themselves to us in our daily practices. Let’s organize around this. Let’s make clinical and translational research a mandate and not an add on for the few survivors. Then we can start to discuss how we can even the remuneration field

  2. Great post. Thanks for thinking about this. US institutions, research is considered equivalent to clinical work. Many other Canadian Institutions try to ensure, researchers are at median of their scale. Some sections in Internal Medicine at U of M it is more equivalent either because of practice plans or non FFS. No overall easy solution in Manitoba.

    Phenotype comment is debatable. Very few people are at the end of the binomial curve. How others do often depends upon multiple factors, including resources, environment and structural issues, along with their own efforts. A common saying is people who were funded/ resourced well did better than those who were not. How can it be otherwise?

    Regarding “Should clinicians with a major research commitment be remunerated at the level of their PhD researcher peers who undertake comparable initiatives? Or, alternatively, at the level of their FFS peers? Or somewhere in between?” depends upon how the system views clinician scientists and research. If value is much lower than clinical work, for sure they should be remunerated much less than pure clinicians. And perhaps most research left to PhDs. If PhD researcher peers are undertaking comparable initiatives, what is the need to have clinicians do research? Better value for the money spent on their training/experience/expertise would be to let them do clinical work.

  3. I am somewhat reluctant to comment but you have opened this can of worms and I cannot let it pass . Whether we like or not we have to compete in this academic universe for people and resources and everyone is aware of the financial constraints that you both allude to. These are not new and they are no worse than several times in the past.
    In 2001 the total research salary available to the department was about 580,000 dollars. We were a research backwater. Only one women had 50% or greater research protected time and competitive grant support was comparable to Memorial University.
    Fourteen years later we had more than 1.8 million in research salary, there were six women investigators with 50% or more research protected time and we were finally punching at our weight class in competitive grants for the first time in a generation.
    Most of that salary was created either through new endowments or diverting cash away from inefficient areas of expenditure.
    It is correct that one role of leadership is to manage expectations but not only in one direction. We will not succeed by invoking our own local brand of asceticism.
    Experience tells me that researches become miserable over time when they don’t make the median income within their section .No doubt that target becomes challenging in high earning sections but that barrier is not insurmountable. The first role of leadership is finding money ;either creating it or diverting it from other concerns .Getting more money would be a much more productive subject for discussion.
    Those plaques hanging down the corridor aren’t hunting trophies ; they’re salary engines and donor magnets.

  4. As a lab -based clinician scientist for nearly 30 years I have often felt like I have lived in 2 separate full-time worlds: That of a (hopefully) up to date, informed clinician and peer and trainee mentor and educator like my MD colleagues, and conversely a single-minded (necessarily) CIHR-funded researcher with stellar graduate trainees like my PhD colleagues.
    This duality forces most clinician-scientists, to sacrifice an aspect of either their personal life, their health or to neglect some aspect of their work role, and may explain the observation of the small number of female clinician scientists who remain in their roles especially if they are lab-based. Remunerating these individuals, who have a sense that they are doing two jobs at a rate that is less than the median of their peers, and who observe that they are paying a higher price personally for their career, will continue to give the message to clinician-scientists that clinicians as researchers are not seen to the research endeavor.
    Medical Centres with successful clinician research programs make research the central pillar of their institution because they know that the most innovative and capable clinicians and scientists want to practice in settings that are known to be cutting edge research centres. Hence a circular feedback loop is established. These centres pay the best researchers a lot, pay all of their researchers on par with the clinicians and heavily tithe the highest 25% of income earners to do it.
    Partly due to such high clinical volumes which also do not allow much protected time, the University of Manitoba Department of Medicine’s members I would suggest have higher average clinical incomes than both Toronto and Vancouver’s academic centres, so I think there is room to reconsider the scheme considering the cost of living. There would be dissent from some department members especially certain sections, but leadership is about doing the right thing in spite of dissent sometimes.

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