Assoc. Prof. Karolis Ažukaitis: Clinician-Scientists Are a Driving Force Within the Self-Learning Health Ecosystem

A clinician-scientist is at once a physician and a researcher, someone who transfers knowledge between the science of medicine and daily practice. By merging and transmitting the most up-to-date information, these professionals help both the science, building the best patient care possible, and physicians, working in direct contact with patients, to develop. However, clinician-scientists usually take on even more roles that are just as important: they are teachers, transmitting cutting-edge knowledge to their peers and students, communicators, educating the broader society and leaders, contributing to healthcare policy-making and the development of a better-operating healthcare system.

The many roles clinician-scientists perform simultaneously and the reasons why this is a challenging career path that fewer and fewer people follow are discussed in the recent article, 'Structured Programs to Train the Next Generation of Clinician Scientists', co-written by a team of researchers from Germany, Belgium, the Netherlands, Spain, Switzerland, and Lithuania. It was recently published in the prestigious science journal Nature Medicine. We interviewed one of the authors, Dr Karolis Ažukaitis, Associate Professor, paediatric nephrologist, and Vice-Dean for Research and Innovation at the Faculty of Medicine, Vilnius University.

High standards are hardly compatible with the working conditions provided

– Clinician-scientists are probably some of the fastest learners in medicine. This professional development is happening in two directions at once, and intensely too, as one must also keep up with the cutting-edge technologies. Is such a person basically pursuing two careers?

– True, it may seem that this is about two parallel careers, but actually, it should be regarded more like two intertwined roads. A physician who is also a researcher is constantly developing and able to look at many healthcare processes from a different perspective: they look critically at the current practice and notice knowledge gaps that pose challenges in their daily work. As a researcher, they know best what needs to be researched, how, and why, and, crucially, are able to turn difficult clinical questions into testable hypotheses. In the constant flow of new scientific knowledge and discovery, our healthcare ecosystem needs people who can help transform this knowledge into practical solutions and take relevant questions back for more research. Such people transfer the freshest scientific knowledge into clinical practice and become their disseminators, so, being part of a huge ecosystem, they inspire progress and the development of the whole healthcare system.

– Can clinician-scientists work alone, or do they need a team? If so, how many people are involved?

– One person cannot whistle a symphony; you need a full orchestra for that; the medical and health-science elements, and in particular, the transfer of knowledge into practice, are especially complex processes. A clinician-scientist has to be a leader, colleague, coworker, and teacher, seeking to ensure the highest quality standards in research and patient treatment. They are expected to innovate and unite different disciplines to achieve a common goal. So, of course, they have to have a team and need to recruit and train new people. Moreover, a team should not be comprised of just one specialist. In this mechanism, every one of them may have their function: that of an administrator, physician, or other healthcare professional, directly conducting research, a lab researcher, and finally, a lead scientist, who would pave the way for more clinician-scientists.

– Do we have a lot of such people in Lithuania?

– We do have many active physician-researchers. However, although de facto they operate as clinician-scientists – they practice medicine and do research – we cannot call them that in the strictest sense of the term because, to this day, they don't have the right conditions to do their job. One of the crucial things in this field is time and workload distribution. Besides clinical workload, clinician-scientists have to have a safe window to do their research or go on a traineeship. Once they initiate a clinical study, they should receive full support in such areas as collecting data, coordinating a study, developing a project, writing reports, etc. These specialists often need people who are not even part of the medical staff.

There aren't any clearly established models that would define the working conditions and remuneration of the time dedicated to science for physician-researchers in Lithuania. Academic medical institutions in Germany and a number of other countries apply a 50/50 or 80/20 model: a person doing both scientific and clinical work can, for a certain period of time, reduce their workload as a physician and dedicate more time to scientific research. Their opportunities also relate to the appropriate funding of such research. Indeed, the long timescale of research and lengthy wait for results often require a lot of funding.

Furthermore, the peculiarities of medical research are sometimes hardly compatible with the requirements of research-funding institutions, which aren't tailored to various branches of science. It generally takes from 5 to 8 years to get clinical research results because the patients under treatment have to be observed for a long time. Unfortunately, the research-funding mechanisms that are available in Lithuania often set a timeframe that is too short to conduct the research, publish the results and therefore offer funding that is insufficient, and the mechanisms themselves aren't flexible enough to enable medical research of the highest quality. Obviously, distributing resources among different branches of science is a difficult task, but we have to keep in mind that medical research may not only create direct value for patients and medicine itself but also significantly contribute to the development of a more effective, highest-quality healthcare system, which all of us depend upon.

– Could you paint a picture of the clinician-scientist's career? How many years does one need to study, where should one apply, and how much should one invest in self-development? Is it possible to work as a physician for a few years and then dedicate a few years to science alone?

– Usually, it follows a path of continuous work, requiring constant investment and cooperation with the international science community, which stimulates the scientist to initiate research. You cannot afford long pauses in this profession. There are some models that work abroad, where a person can manage a unit for a while, do clinical work, and then devote their time to research, co-conducted with colleagues in the academic community. Such a path is available in hospitals tied to first-class universities, and, by the way, healthcare facilities that practice academic medicine usually show much better patient outcomes. These facilities see their patient care standards evolve, motivate their employees, and attract more talented specialists. In this environment, a self-learning health ecosystem forms.

The clinician's engagement in scientific work does not necessarily have to be exponential: the person may occasionally participate in a study as a co-researcher involving patients but may also constantly generate ideas and test them. The path itself is often long because, in addition to professional (residency) studies, one requires a doctoral degree. Well, you can start your doctoral studies before finishing your residency. I think this is a more attractive scenario for young physician-researchers, but it's important, at least for that period of time, to firmly focus on those two studies rather than the search for additional income.

– Can the potential for a career as a clinician-scientist be evident during medical studies, or does it reveal itself naturally once you start working?

– The potential consists of the inclination and natural gifts of the potential clinician-scientist, as well as the right accompanying conditions for following that path. One can become interested in science both during one's studies and later in life. Either way, it's going to be challenging, only in a different way. Students don't have a right to work directly with patients, so it's difficult to raise clinical questions, identify your area of research and find a supervisor. Besides, students are caught in even more dilemmas, for example, which area of medicine to choose, whether to work with children or with adults. You shouldn't be wary of jumping between different disciplines or getting disappointed if something comes to a temporary halt. It's worth remembering the hedgehog concept: a fox knows many things; it jumps around, skipping from one thing to another, whereas a hedgehog is trotting down its path and knows one good thing – if somebody attacks it, it will erect its spines. You need to tap into your inner hedgehog and ask yourself: What am I passionate about? What am I best at? What are the conditions available to me at the moment?

A person can also follow the clinician-scientist's path after studies while working at a hospital, but at this stage, new limiting challenges appear. It's a time when people are creating families, buying homes, and need to achieve financial stability. It often weighs on them emotionally, and if you add a scientist's load to the mix, you end up with a unique problem. However, the value is also unique: we feel it directly when we treat people, and it's less noticeable when we contribute to the development of the whole healthcare system little by little.

Clinician-scientists – an endangered species?

– When does a clinician-scientist experience joy in their activities?

– Those who enjoy the scientific process are simply glad to take part in it; achieving a breakthrough in a discovery-based science on your own is very difficult. I think that clinician-scientists find the biggest joy in a dynamic (usually international) scientific community, honing their skills and sharing knowledge with others, perfecting their clinical practice, and seeing that those developments actually work.

– Does the current national healthcare system incentivise physicians to do research and researchers to follow the clinical application nuances of medical treatment? Might it be that the companies that produce specific technologies are even more interested in the professional development of physicians?

– The private healthcare sector cares for people participating in research, but it has developed its own applied scientific research and experimental development sector. Hospital-working physicians are often needed for them as contractors to test what they've developed. For the state, every clinician-scientist is an investment made for the country to provide a better hospital and healthcare standard overall. Therefore, the state should dedicate specific funding and provide a flexible mechanism. We have to decide what clinician-scientists contribute towards medical progress and the whole healthcare system and try to calculate the potential value of that. If it does create value in the healthcare system, shouldn't it then be funded collectively, using healthcare money? If we recognise this as one of the segments that would allow us to better, faster, and more effectively help people, I have to raise the question: How is that different from reimbursable medicines?

– The situation you and your co-authors describe in the article – that clinician-scientists are like an endangered species – sounds worrying. In addition, these people are under huge stress and, as stated in the article, go through 'valleys of death', with significant dropouts during certain more vulnerable career phases. Why do we need this species of researcher to persist, and what will happen if we don't encourage young people to take this path?

– A few years ago in Hanover, during a conference of clinician-scientists from across Germany, colleagues described the value a clinician-scientist generates – it would become painfully obvious if we withdrew our scientific efforts from major hospitals and the healthcare system in general for ten years. If I had a garden and weeded, watered, and fertilised it every day, would someone be able to tell how much each small action I had taken contributed to tastier tomatoes? No. But if I didn't do any of that, the results would be very easy to measure. Recovering, once everything's wilted, would be very difficult, so we shouldn't go down that path. Clinician-scientists are an integral part of medicine, as much needed as good health managers, practitioners, professional, kind staff, a good organisational culture and, more broadly, a good healthcare community culture.
Following good practice and deepening our understanding of better prospects.

– Why wouldn't taking medical knowledge from foreign researchers and adapting it here be enough for us?

– Once you acquire knowledge, you have to know how to appropriately apply and critically assess it. It is never 100%; we often receive it systematised and summarised in the form of guidelines and recommendations. If we simply kept following it, we would never be at the forefront; this would result in frozen progress and quality. In order to adopt innovation quickly, effectively, and in appropriate situations, we must have experts in the field to discuss this with, as well as active scientific competencies. We implement innovation methodically and, accordingly, teach students research methodology so they would be better equipped to make clinical decisions. The skill of making clinical decisions is the most important tool in the clinician's toolbox, often more important than a dialysis machine, scalpel, or endoscope, and this decision-making requires a grasp of the origin of medical knowledge and the main principles of the scientific method.

– In the article, you discuss the drawbacks of clinician-scientist training programmes and suggest the direction in which they should be changed. Would it be fair to say that more active cooperation with patients is one of the important points?

– Patient involvement is crucial in identifying research priorities because research funding is limited. At the end of the day, medical science should first solve patient problems, not those of physicians, right? Of course, we should note that physicians also do research that is intended to increase the effectiveness of the healthcare system, shorten hospitalisation time, and enable us to distribute resources more effectively, all of which the patients benefit from indirectly. Nevertheless, the patient doesn't care that much about how their test results change if that doesn't really affect their symptoms (for example, chronic fatigue) or lifespan. The symptoms that prevent them from going to work, having a personal life, or functioning normally may get ignored. Then family relationships deteriorate, children suffer, and their school marks get worse. These consequences are not measurable. Hence, in doing medical research, it is important to find a balance between the direct priorities of patients and things that are important purely from a medical perspective.

Patients should be our partners, but that requires a certain level of patient maturity and a purposeful cooperation format. Clinician-scientists should ask: Is the study well-planned? Will patients be willing to participate till the end? Do patients think that a particular scale would be suitable for measuring tiredness? Or maybe they don't even understand what they're being asked? Having gauged how patients felt through standardised tests, clinician-scientists could point medicine in an improved direction and better meet the needs of their patients.

– The training of clinician-scientists requires separate attention; this was first noted in Germany, where, a few decades ago, a study programme was established in Hanover intended specifically for training these professionals. How is this field being further developed?

– Many different models have been developed because every country has its own unique science, study, and healthcare systems. In Germany, projects are funded via tenders: younger students can work 50/50 as scientists and clinicians, whereas older ones dedicate 80% of their time to research. Later, thanks to external funding and the generated value, this investment yields 5-fold returns, creating positive conditions for new clinician-scientists to do research.

In other countries, the portion of work time to be dedicated to science is prescribed in the employment contract, or, for example, the clinician-scientist is defined as a separate category in legislation (as is currently the case in Spain). An MD-PhD programme has also been developed, in which doctoral and residency studies are combined with the latter in shortened form because students doing research in their clinical field improve their clinical competencies, too. There is also a negative incentive model in which students cannot apply for a challenging residency speciality or job without a doctoral degree.

In Lithuania, however, we can work part-time at a hospital, but that doesn't oblige us to dedicate the rest of our time to research. We don't have security or flexibility due to the ever-changing circumstances. This is closely related to limited and sometimes short-sighted health and science system funding, rigid labour laws and requirements imposed upon hospitals and universities by their regulating institutions. Two separate career paths form, where no one is ensuring work continuity or the vision of where these two roads will take us. We should follow the good practices of other countries and try to adopt some of them in Lithuania. At least, as the views on the management of the healthcare system and facilities are changing, we are finally starting to talk about clinician-scientists and discuss the issue with our closest clinical partners. I'm sure that through cooperation with healthcare leaders and entertaining a common vision, we will find ways to overcome the barriers and lay the foundations for clear and sustainable clinician-scientist prospects in the future.