Stethoscopes and test tubes – getting the best of both worlds

Talk us through the importance of clinician scientists within cancer research…

Clinician Scientists are vital to the success of cancer research.

In particular, they work at the interface between fundamental discovery science and clinical application.

Clinician Scientists frequently drive both early phase clinical investigations, especially critical experimental medicine studies, and the translational analysis of patient samples. This combination of translational research and patient intervention is vital as we endeavour to move basic science into novel treatments and biomarkers.

Last year, the UK House of Lords Science and Technology Committee reported an alarming decline in the number of clinical academics in the UK – why do you think that is?

Well, firstly it’s important to emphasise there are existing opportunities for clinicians in the UK to undertake research as part of their clinical training – including Academic Foundation Programmes, Academic Clinical Fellowships and PhD programmes for clinicians, with post-doctoral Academic Clinical Lectureships and Clinician Scientist Fellowships for the truly dedicated. These are vital and we must continue to support them.

But it’s true that there are several issues that act as barriers to academic careers for clinicians.

There is a significantly reduced emphasis on basic science in medical school, with fewer students taking an intercalated BSc during their undergraduate training. In addition, funding opportunities for clinical academics, especially following a PhD, are rare and hugely competitive and many fewer candidates can be funded than we would like.

There are also fundamental structural issues: the alternative to an academic career is an NHS job, where clinicians will have total job security, few teaching commitments and will not be dependent upon grants and publications. For budding academics who do not want a purely laboratory research career as a Clinician Scientist Fellow, the alternative is a Clinical Senior Lecturer post – the first permanent academic position for clinicians, linked with honorary consultant status in hospital specialties. However, the prospect of this may seem far less attractive than an NHS post because for these Clinical Senior Lecturer positions – with 50% NHS time and 50% university time – there is a significant teaching load and requirement to generate grant income. It’s also relevant that, given the enormous pressure on the NHS, the ‘50%’ is frequently more like 60% or 70%, which makes a research career almost impossible.

There is also the challenge that Universities and NHS hospitals are separate organisations, often with competing demands.

Finally, and at risk of being overtly political, Brexit acted as a major deterrent to talented European clinicians from coming to the UK to pursue a clinical academic career.

How about the rest of Europe, or indeed globally, who is doing good things to allow clinician scientists to flourish?

From my conversations with colleagues across the world, attracting and retaining clinical academic staff is an international problem. The commonest concern is the balance between clinical and research time, and how to ensure protected research time away from the clinic.

I know that the German Federal Government has recently established both Clinician Scientist and Advanced Clinician Scientist programmes in response to widespread concerns about clinical academic careers. These are funded at institutional level rather than to individuals (like the CRUK Clinical Academic Training Programmes for PhD funding) and will ensure that major centres have cohorts of early career clinical researchers working in aligned themes in each Centre.

Also – it’s worth noting that at many of the main Centres in the US and Germany, the hospitals are owned and run by universities, and as such research is perhaps more closely interweaved into clinical care.

What more do you think can be done to entice, and keep, researchers with a medical background into cancer research here in the UK?

As I mentioned, there are multiple opportunities for clinicians in the UK to undertake research as part of their clinical training and we must continue to support them.

However, there are other issues for which there are no simple fixes, and which will require multi-level intervention over several years. In no particular order.

1. Re-introduce scientific training in medical school.
2. Expand current National Institute for Health and Care Research (NIHR) academic training programmes, especially Academic Clinical Fellowships and Academic Clinical Lectureships.
3. Continue to fund Clinician Scientist Fellowships, such as those CRUK and other funders provide, at least to the current level and preferably expand.
4. Increase support following a PhD to allow keen clinicians to remain research active.
5. Expand the number of Clinical Senior Lecturer posts in universities and ensure that the post-holders have time to succeed in their research, with realistic research goals and realistic teaching loads.
6. Ensure protected research time for NHS clinicians. There are many NHS clinicians with are keen to participate in research, especially as clinical trialists, but who do not wish (for multiple reasons) to be a university-employed clinical academic and have zero time in their jobs for research. Providing these doctors with genuine protected research time (at least one day per week) could be transformational. The importance of this was shown in the Creating Time for Research report.
7. Clinical trials fellowships – train clinicians into how to run clinical trials and how to be trialists.
8. Work closely with industry – nearly all clinical trials of novel drugs require interaction with industry, and we should embrace pharma, both large and small. We should develop internship programmes and give our trainees education in how to work with industry.

What was it that tempted you to get into research?

I was at a medical school where everyone undertook an intercalated degree. We were inculcated with the importance of academic medicine throughout our training, and we were surrounded by inspirational senior figures who personified what academic medicine could and should be.

Therefore, an academic pathway was effectively my default option. Like many medical students, my exposure to oncology was fairly minimal during undergraduate training… only two weeks in 6 years if I remember correctly. However, during my junior medical posts, I realised that cancer was fascinating and that there were almost unlimited research questions to be addressed. Because of that I started my PhD almost immediately after junior medical jobs, and I haven’t looked back.

You are co-chair of the CRUK research careers committee – how is CRUK growing the clinical academic community?

The research careers committee does a really important job for clinical academics – the headline of what we do is to choose Clinician Scientist and Advanced Clinician Scientist Fellows.

These are clinicians who have undertaken a PhD, have (largely) completed their clinical training and now wish to embark upon a true academic career – with 80% time dedicated to research. This is usually laboratory-based and always focussed on clinically relevant questions in their cancer type of interest. These Fellows are uniformly hugely impressive, and it is a pleasure to be able to support them on their pathway to glory! I only wish we were able to fund more of them.

The less heralded but equally important part of the RCC remit for clinicians is to fund bursaries. This is funding given to junior doctors at two key stages in their careers. The pre-doctoral scheme aims to support those who have no or little research experience, giving them the first taste of cancer research and allowing them to obtain data to support a PhD Fellowship application. The post-doctoral scheme aims to support candidates following their PhD, to enable them to remain research active as they complete their training and to allow them to be competitive for Clinician Scientist Fellowships.

We all recognise the significant gap that is required from PhD to Clinician Scientist Fellowship, and these bursaries are a very important bridge over that gap.

Although the sums are relatively small compared to a five-year Fellowship, these bursaries can make an enormous difference to the funded doctors. Indeed, bursary funding like this at the very start of your research career is a huge amount and can act as the catalyst to a whole research career.