Wearing two hats, part 2

A while back, I wrote about the difficulties of wearing two hats, that of the basic scientist and that of the clinician. In that post, I wrote more in general about the problems of having dual roles and the perceptions of those around me as to my credibility and competence in each role. Having allegedly "made it" now by producing compelling enough evidence coupled to a persuasive enough case for my planned research to convince the NIH to fund my research proposal (not to mention having published a few papers on my own in good journals), I can correctly say that I have joined the ranks of credible basic scientists. (Whether I am an outstanding--or even a good--scientist or not remains to be seen). In any case, somehow I've now built a reasonably well-funded laboratory and can afford to have a few people working for me to grind out data. On the other hand, I'm still a clinician. I also happen to be on call this week, and when that happens, the practicalities of wearing two hats start to weigh on me more than at other times, because it is at these times that my clinical responsibilities increase to the point where they put more pressure on my research responsibilities.

As I mentioned before, one of the biggest difficulties in combining a research with a clinical career is finding the time to do the necessary work to get a credible research program going. This includes doing the background reading and developing the research plan, doing the research, writing grant applications to get funding to support the research, and writing up the research to submit to peer-reviewed scientific journals. Several "pure basic scientists" pointed out that they have problems with this, too, because administrative and teaching responsibilities eat into their research time. No doubt this is true. I have little doubt that basic science departments pile on teaching and/or administrative responsibilities in a quantity that makes it difficult for young basic science faculty to succeed in getting a research program off the ground, getting funded, and publishing enough to prove themselves to be credible scientists and thus build a reputation for themselves. For a moment, however, I would still like to address why their situation is not and cannot be the same:

If a basic scientist fails to fulfill his teaching or administrative duties or doesn't fulfill them well, no one is going to die. Nor is anyone going to suffer a complication or additional pain. Patient care often can't be put off, at least not for long. Unlike teaching, it can't always be scheduled or predicted.

It's that simple. And that stark.

That'sthe difference. It's 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, they were awful in the classroom. There were even more faculty who were just OK in the classroom, but--again--ran 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, it's just the nature of the beast. You can't be bad or even mediocre as a physician, regardless of whether or not you are a scientist as well. You just can't. If you are, you have no business treating patients. You have to be at least competent as a physician or surgeon, and preferably you should be excellent. It's 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.

Maintaining one's 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 most of us manage it is to focus their clinical practice like a laser very tightly on one specialized area. That's the practicality of it. The necessity for competence when you don't get as much experience and practice as a straight clinical surgeon usually mandates focus. Even then, it's difficult. As a part-time surgeon, I don't do nearly as many cases as a full-time surgeon, and, as long as I am doing research, 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 that's usually less of a consideration compared to the basic science faculty with significant teaching responsibilities. I'm in essence a part-time scientist as well. I can't 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. 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 I'm 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. That's why another essential practical necessity for success is to have good people working for you and good collaborators working with you. One bad hire can destroy your lab's 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 aren't 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 doesn't respect weekends or nights. Moreover, the natural tendency is for patient care responsibilities to grow slowly and inexorably. In essence, you can be a victim of your own clinical success, and your success in the clinical realm can negatively impact your success in the scientific realm. I know one surgeon who has become so popular that he just can't cut back his clinical practice without risking a backlash from his referring physicians. It can go the other way, too, but when that happens the usual solution is to give up clinical practice.

Let's look at a few real-life scenarios that illustrate the conflict. 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 take care of the patient and trash your experiment. You could ask one of your partners to deal with it, but they have patients of their own to deal with; they're all either in clinic or in the operating room. Besides, it's your complication. You need to deal with it, because that's what surgeons do.

Scenario number two: You have a grant due in a few days. You thought you had planned well, canceling your clinic that week several months prior and telling the schedulers not to schedule any operations that week, 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. (Hopefully, you don't have a boss that does this to you on a regular basis. Fortunately, mine don't and even bend over backwards sometimes to prevent such things from happening.)

Scenario number three: You have a grant due in a few days. The day before your grant is due just happens to be your clinic day. It would inconvenience 20-30 patients if you were to cancel your clinic, and you're so busy anyway that it would be hard to find spots for them in a short period of time; so you don't cancel the clinic and resolve to have the grant ready a day early. Unfortunately, a couple of emergencies (like scenario one) keep you from having it quite ready. Do you cancel clinic and inconvenience all those patients so that you can get your grant done?

Scenario number four (perhaps the most common scenario): Your clinical load has been slowly growing. Almost without your realizing it, you 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, because senior basic science faculty often find themselves no longer doing benchwork after a certain period of time. 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. There are a pile of manuscripts that need to be finished, but you can't get to them because you're 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. You'll soon be due to try to renew your grant, something you have no idea if you'll 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. Your referring physicians will also 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 is also less interested in practicality and more interested in intellectual pursuits, in 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. It is also much more emeshed in human contact and human relations that the world of the scientist in a way that the world of basic science. It is much less possible than it used to be for the lone scientist to labor with little human contact, but it is still possible for a scientist to labor with little human contact outside of the coccooned world of his department. It is not possible for a clinician (other than a pathologist) to do his job without dealing with many, many people every day, often at their most vulnerable or difficult to deal with. The clinician is always dealing with new patients and new people, and it's hard to succeed as a doctor without being able to deal with people. (Yes, I know that a fair number manage.)

The clinician-scientist tries to bridge the gap between these two worlds. Clinician-scientists bring a unique perspective to the study of human disease that neither a pure clinician or a pure scientist alone can. Nothing is 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.

I hope to pull that off one day.

In fact, I'm beginning to think that clinician-scientists represent an eminently practical way of doing translational research.

[Note: I may have to write a third part of this series some day on the ethical issues of wearing two hats and doing clinical research involving human subjects, as mentioned by Dr. Maurice Bernstein in a comment in my previous post on the matter.]


  1. "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."

    I hope you meant, "your spouse and children" ;)

    Anyway, excellent (and fascinating) post...

  2. I'm a guy. I have a wife. That's why I said it that way. You have a point, though.


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