National Institutes of Health Funding in Plastic Surgery: A Crisis?

Correlation of Scholarly Activity and Departmental Clinical Productivity in a Surgical Subspecialty

INTRODUCTION

Promotion within academic surgery involves demonstrated excellence in administrative, clinical, and scholarly activities. The present study analyzes the relationship between scholarly and clinical productivity in the field of reconstructive microsurgery.

METHODS

This is a retrospective cohort study of microsurgery fellowship directors (MFDs). Data on clinical productivity were obtained from the American Society for Reconstructive Microsurgery and scholarly productivity from Scopus. Outcomes were department annual free flap volume, number of publications, and h-index. Descriptive statistics were calculated, and nonparametric tests were used to compare continuous variables.

RESULTS

Thirty-nine MFDs were included in this study. All were plastic surgery residency trained and 38% trained under the independent training pathway. Most underwent formal fellowship training in reconstructive microsurgery (89%). The top three microsurgery fellowships trained 37% of all MFDs. Twenty-five percent of MFDs trained at the institution where they ultimately became program director. Twenty percent of MFDs had an additional degree (4 MS, 2 PhD, and 1 MBA). The median number of annual free flaps performed per institution was 175 (interquartile range [IQR] 122). The median h-index was 17 (IQR 13) resulting from 48 (IQR 99) publications. There was a correlation between department annual free flap volume and h-index (r = 0.333, P = 0.038).

CONCLUSIONS

There is a correlation between academic productivity of MFDs and the clinical productivity of their department. This study provides a benchmark for aspiring reconstructive microsurgeons.

[The Impact of Industrial Sponsorship on Research Findings in Randomised Clinical Trials in Plastic and Aesthetic Surgery: a Cross- Section Analysis of the Past 12 Years]

BACKGROUND

Industry funding of research studies can cause the results in the field of plastic, reconstructive and aesthetic surgery to be biased towards the sponsors. This paper aims to review randomised clinical trials (RCTs) published by leading international journals in plastic, reconstructive and aesthetic surgery with respect to characteristics and possible industry-friendly conclusions in favour of those funding the study.

MATERIAL AND METHODS

Characteristic data and funding of RCTs published by leading international plastic surgery journals from January 2010 to January 2022 were evaluated. The studies were categorised based on their thematic focus and the results in light of the existing funding.

RESULTS

A total of 381 RCTs were included in the analysis, 68.5% of which were from a university (n=261). The larger proportion of studies did not disclose any information about the research funding. While 26% (n=98) of the studies analysed were funded by companies, 9.7% (n=37) were funded by universities/the government (p<0.05, 95% confidence interval). The overall focus of private clinics was aesthetics (n=32). Generally, the topic aesthetics (n=153) was funded by industry in 28 of 100 cases (28% industry/private sponsors compared with 9% university/government). Regarding reconstruction/burns/hand surgery, 9.2% of studies were funded by companies/private sponsors. Funding for research by university-based institutions was industry-sponsored in 25% (n=64) of cases. Regarding industry-sponsored studies, 73% (n=71) of the results were product-friendly in their conclusion (p<0.05, 95% confidence interval) and placed their thematic focus on therapeutic drug/product application (n=50, 75%).

CONCLUSION

In terms of funding, industry and private sponsors take a leading role both in reconstruction and aesthetics. Nonetheless, the majority of the evaluated studies were not financed by the private sector. In cases where the research was funded by private companies, the results were significantly in favour of the product. Aesthetics as a focus is currently more frequently funded by industry than reconstruction, burn, and hand surgery.

NIH Funding Across Surgical Specialties; How Do Women Fare?

BACKGROUND

Much has been written about the under-representation of women in academic medicine. However, no study has comprehensively described the gender-based trends of National Institutes of Health funding across surgical specialties; this study provides such an overview.

METHODS

We queried a previously created database to identify both male and female National Institutes of Health-funded surgeons. Surgical specialties and subspecialties were determined based upon formal training. Total grant costs and average costs per R01 and K grant were calculated and compared. Bivariate χ2 analyses were performed using population totals.

RESULTS

In 2020, the specialties with the highest proportion of National Institutes of Health-funded female surgeon-scientists were obstetrics and gynecology (57%) and vascular surgery (40%). The general surgery subspecialties with the highest proportion of women were breast (85%), endocrine (58%), and colorectal surgery (40%). An analysis of total grant costs in 2020 revealed that in most specialties, the proportion of funding held by women was substantially less than the proportion of women investigators. In obstetrics and gynecology, women comprised 57% of surgeons, but held only 46% of the funding. Similarly, in breast surgery, women comprised 85% of surgeons, but held only 45% of the funding. Women and men had similar changes in the average total cost per R01 and K grant awarded from 2010 to 2020. In 2020, women were awarded less than men per R01 grant in general, otolaryngology, plastic and reconstructive, urology, and vascular surgery.

CONCLUSION

Although female surgeon-scientists have made significant advances in some surgical specialties, they continue to lag in others. An in-depth analysis of the factors contributing to these trends is necessary to achieve gender parity across all academic surgical specialties.

A 20-Year Analysis of Global Authorship Trends in Craniofacial Literature: Is the United States Falling Behind?

INTRODUCTION

Recent advances in craniofacial surgery have occurred in conjunction with a global proliferation of research. Although previous studies have examined geographic publication trends, little is known about these trends in the craniofacial literature.

METHODS

All craniofacial articles published from 2000 to 2020 in 3 premier craniofacial surgery journals were evaluated in 5-year increments. Geographic origin, manuscript type, and authorship characteristics were collected. Changes in publication output, geographic origin, and content were analyzed.

RESULTS

In total 3864 articles were analyzed, with the United States (U.S.) (33.46%) accounting for the majority, followed by Asia (27.04%), the Middle East (16.23%), and Europe (14.65%). The proportion of articles from the U.S. decreased significantly in the in the 20-year span (48.28% versus 33.53%, P < 0.001), whereas those originating from Asia and the Middle East increased significantly (18.62% versus 31.41% and 10.34% versus 15.66%, respectively, P < 0.001). After stratifying and selecting for regions with the greatest changes in publication output, the authors observed significant trends for the number of original investigations from 2000 to 2020 in the U.S. (Odds Ratio [OR] 1 versus 2.4, P < 0.001) and in Asia (OR 1 versus 1.8, P = 0.0052). Additionally, a significant trend in editorial/correspondence publications originating in the U.S. (OR 1 versus 0.74, P = 0.0102), Europe (OR 1 versus 0.38, P = 0.0186), and Asia (OR 1 versus 0.48, P = 0.0051) was observed.

CONCLUSIONS

Despite rising craniofacial publications over the past 2 decades, there has been a diminishing proportion originating from the U.S.

A Primer for Success as an Early Career Academic Plastic Surgeon

The early career academic plastic surgeon strives to be an expert surgeon, an innovative researcher, and an impactful educator. Navigating these challenges is difficult in a healthcare landscape with diminishing public research funding, increasing demand from institutions for clinical productivity, and decreased value of surgical education. To help the junior academic plastic surgeon, this article discusses the fundamental aspects of developing an early academic plastic surgery practice, rooted in clinical care, research, and education.

METHODS

Using published literature, expert opinion, and faculty interviews, the authors prepared this primer for education and guidance of plastic surgery residents considering a career in academic plastic surgery and early career academic plastic surgeons.

RESULTS

This primer highlights elements important to succeeding as a junior academic plastic surgeon including defining goals and priorities, institutional and financial support, mentorship, education of students and residents, developing a practice niche, promotion and tenure, and social support and burnout.

CONCLUSION

The early career academic plastic surgeon can create an environment for academic success with appropriate institutional support, mentorship, personal, and social support, to progress toward promotion while minimizing burnout and professional exhaustion.

Beyond the Scalpel: Attracting and Nurturing Surgeon-Scientists in Plastic Surgery

SUMMARY

With plastic surgery being at the forefront of innovation and discovery in multiple research disciplines, plastic surgery is poised for M.D./Ph.D. and research-focused M.D. trainees to be attracted to this field. Surprisingly, recent reports have shown that the number of surgeon-scientists pursuing research is on the decline, with these declines being even more pronounced within plastic surgery. It is essential that plastic surgery remains a leader in translational research by cultivating a group of individuals who have been trained in basic research and are thereby competitive to obtain extramural grant funding. To address this need, the authors review data elucidating why the research-oriented trainee may forego pursuing a career in plastic surgery. Although much of the existing literature is speculative, the authors identified the current number of M.D./Ph.D.s in plastic surgery using data obtained from the American Society of Plastic Surgeons and investigated number of grants in plastic surgery compared to other medical and surgical fields using the National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results. The authors hypothesize that economic constraints and difficulty securing protected research time may be contributing to fewer trainees pursuing plastic surgery. The purpose of this article is (1) to discuss potential reasons deterring research-oriented trainees from pursuing careers as surgeon-scientists within plastic surgery; (2) to propose solutions that may attract more trainees interested in careers as surgeon-scientists to the field of plastic surgery; (3) to highlight the lack of quantitative data regarding surgeon-scientist training in plastic surgery; and (4) to propose and encourage future research avenues to help attract and nurture surgeon-scientists in plastic surgery.

Majority of Most-Cited Articles in Top Plastic Surgery Journals Do Not Receive Funding

BACKGROUND

Plastic surgery faculty, residencies, and institutions are frequently judged on the quantity and quality of their research output. Some of the most impressive individuals in the specialty receive financial support in the form of grants and payments to help with research ideas.

OBJECTIVES

The authors sought to discern if funding directly correlates to greater impact in the top plastic surgery journals as measured by citations.

METHODS

Using the Web of Science database, the authors identified the 50 most-cited articles in each of the top plastic surgery journals from January 1975 to August 2020. The articles were scanned for funding sources and categorized as industry, federal, foundational, and institutional, while stratifying by decade.

RESULTS

Between 16 journals, 13.3% of the most-cited articles received funding, 2.6% of which came from industry, 5.4% from government, 4.4% from foundations, and 0.86% from institutions. The percentage of most-cited articles and the proportion that received funding were both correlated with decade (P = 0.0017 and P = 0.043, respectively). However, only the percentage of articles was found to significantly increase over time (P = 0.0068).

CONCLUSIONS

Although funding leads to meaningful publications, this study showed that financial support is not required to have an influence in plastic surgery research.

A Report on the Representation of Women in Academic Plastic Surgery Leadership

BACKGROUND

The year 2017 marked the first year women comprised a majority of U.S. medical school matriculants. While more women are pursuing surgical training, within plastic surgery, there is a steady attrition of women advancing in leadership roles. The authors report the current status of women in academic plastic surgery, from trainees to chairwomen and national leadership positions.

METHODS

The Electronic Residency Applications Service, San Francisco Match, National Resident Matching Program, Association of American Medical Colleges, American Council of Academic Plastic Surgeons, Plastic Surgery Education Network, and professional websites for journals and national societies were accessed for demographic information from 2007 to 2017.

RESULTS

The number of female integrated pathway applicants remained stable (30 percent), with an increased proportion of female residents from 30 percent to 40 percent. There was an increase in female faculty members from 14.6 percent to 22.0 percent, an increase of less than 1 percent per year. Twelve percent of program directors and 8.7 percent of department heads were women. Nationally, major professional societies and administrative boards demonstrated a proportion of female members ranging from 19 percent to 55 percent (average, 27.7 percent). The proportion of female committee leaders ranged from 0 percent to 50 percent (average, 21.5 percent). Only six societies have had female presidents. No major journal had had a female editor-in-chief. The proportion of female editorial board members ranged from 1 percent to 33 percent (average, 16.1 percent).

CONCLUSIONS

The authors' study shows a leak in the pipeline at all levels, from trainees to faculty to leadership on the national stage. This report serves as a starting point for investigating reasons for the underrepresentation of talented women in plastic surgery leadership.

Global Contributions and Trends in Research within the Top-ranked Plastic Surgery Journal

BACKGROUND

We aimed to longitudinally study the relative research contributions of US and international plastic surgeons by evaluating publications within the premier plastic surgery journal over the last 2 decades. We hypothesized that even with an increased pressure to publish in this journal, the relative research contributions from American plastic surgeons will continue to be the largest overall and in all subspecialties.

METHODS

Data for the surgical subspecialty, corresponding author's country of origin, and region were extracted from all original articles in 2 randomly selected monthly issues of Plastic & Reconstructive Surgery (PRS) from the last 2 decades to evaluate longitudinal trends. Data were also extracted from all of the original articles published in PRS for the last 3 years to analyze the recent distribution of research output.

RESULTS

During the last 2 decades, the relative proportion of total original articles written by US authors has increased. They have published proportionally more articles in the Reconstructive and Breast field while publishing relatively less in the hand/peripheral nerve field. From the first decade of analysis, US authors wrote relatively fewer articles in the hand/peripheral nerve field, whereas in the second decade, the US authors wrote relatively fewer articles in the Experimental field. In the last 3 years, US authors published relatively fewer articles in the Experimental and Cosmetic fields.

CONCLUSIONS

Each country's scientific productivity in PRS is related to funding, interest, patients' demand, and healthcare market pressure. In this study, we see that these factors influence trends within research publications over the last 2 decades.

Independent investigator incubator (I3): a comprehensive mentorship program to jumpstart productive research careers for junior faculty

BACKGROUND

In the highly competitive environment of academic medicine, junior faculty investigators face high attrition rates due to challenges in finding effective mentorship, securing grant funding, and obtaining resources to support their career development and research productivity. The purpose of this study was to describe the centralized, cost-sharing design of the Independent Investigator Incubator (I³) program as a novel approach to junior faculty mentoring and to evaluate quantitative outcomes for program improvement.

METHODS

In September 2014, the I³ pilot program, a comprehensive mentorship program targeting junior faculty pursuing research careers, was launched. Participants included junior faculty during the crucial first three years of their research careers or during their transition from career development awards to more independent research. Following initial screening, the I³ mentees were paired with a senior faculty "super-mentor" with expertise in either basic science or clinical research. Mentees were provided with robust traditional one-on-one mentoring, targeted feedback from a super-mentor review committee, as well as biostatistician and grant writing support. To assess the effectiveness of the I³ program, we tracked outcome measures via baseline and 12-month mentee surveys. Data collected assessed program diversity, mentee self-assessments, evaluation of the mentoring relationship, scholarship and productivity metrics. Raw data were analyzed using a paired t-test in Excel (P < 0.05).

RESULTS

Results of the baseline mentee self-assessment survey found that the I³ mentees indicated common "perceive deficits" including navigating the organizational and institutional culture, clear direction in achieving promotion and tenure, among others. When baseline mentee survey responses were compared to 12-month responses, we identified strong "perceived growth" in categories, such as Research and Interpersonal Skills and Career Development Skills. Further, productivity metrics at 12-months revealed that roughly 80% of I³ mentees successfully published a manuscript(s). The I³ program has helped generate roughly $12.1 million dollars in investigator-initiated funding after two years in the program.

CONCLUSION

The I³ program allows for shared costs between institutions and increased availability of successful subject matter experts. Study results imply that the I³ mentoring program provides transformative mentorship for junior faculty. Using our findings, we developed courses and an annual "snapshot" of mentee performance for mentors.

Institutional Collaboration in Plastic Surgery Research: A Solution to Resource Limitations

Background:

The current climate of health care reform and research funding restrictions presents new challenges for academic plastic surgery. Collaboration with private enterprise has been associated with greater research productivity in the general biomedical literature. This study seeks to analyze publication trends in Plastic and Reconstructive Surgery (PRS) to evaluate any changes in institutional collaboration over time.

Methods:

Bibliographic data were retrospectively analyzed for all original research and discussion articles published in PRS from 2012 to 2016. The institutional affiliation for each publication was characterized from its author list as solely academic, private, government, or combinations of these (defined here as “institutional collaborations”). Annual National Institutes of Health (NIH) funding data were also collected over the same period, and associations were analyzed by linear regression.

Results:

In total, 2,595 publications were retrieved from PRS between 2012 and 2016, of which 2,027 (78.1%) originated solely from academic institutions and 411 (15.8%) from institutional collaborations. Although the proportion of academic-only publications decreased from 82% to 74%, the proportion of institutional collaborations increased from 10% to 20% (P = 0.038). Concurrently, NIH funding declined from $33.4 billion to a low of $30.7 billion, which was associated with the decreasing proportion of academic-only publications (P = 0.025) and increasing proportion of institutional collaborations (P = 0.0053).

Conclusions:

Traditional sources of academic research funding have been restricted during the politically and financially tumultuous recent years. With no signs of improving access to financial resources from the NIH, academic plastic surgeons may consider diversifying their institutional partnerships to continue pioneering advances in the field.