How does one balance between clinical and research work?
This is an often-repeated question-probably because the answer is never clear. The fulcrum of the balance is not the same for everyone. Let us pause for a while and try to define certain things to bring clarity.
What is clinical work?
This is perhaps best defined as the time and effort involved in direct care of patients. Obviously, it also involves the time spent on organising the system that permits the above activity to take place smoothly.
What constitutes research work?
Technically research involves trying to find answers to the unknown or partially known. This should mean trying to understand the etiopathology of diseases which are poorly understood and finding new ways of managing them better. Broadly clinicians can be involved in clinical research, basic research or both. Clinical research can be prospective research such as observational studies, clinical trials, epidemiological studies etc but could also be retrospective studies. Retrospective studies including case reports and case series basically allow the clinician to share their data with the scientific community. Strictly speaking this may not be ‘research’ but could still be important to trigger ‘research ideas’. Publishing case reports cannot be considered as research.
What is the clinician’s perspective?
The interest and outlook of clinicians vary diversely. 1. Some would like to concentrate only on patient care and have no time or patience for anything else. 2. Some don't mind additional academic exercises such as giving lectures but abhor research. 3. Many clinicians-especially those attached to teaching institutions get involved in research of the retrospective kind. Often, they are drawn into it by the need to support residents or fellows in their thesis work and not by their volition. 4. A few are serious about clinical research and actively pursue this goal. They try to collaborate with other specialties, involve in clinical trials etc. 5. A very small group are true clinician-scientists. For this group, their primary interest is science and research, and clinical work is seen as a necessary evil that they have to put up with in order to make their research relevant.
Is the balance a fixed ratio between clinical work and research?
Unfortunately, the fulcrum of balance is like a shifting goal post. The point keeps shifting based on 1) the basic level of interest in the activities (as elucidated above) 2) The changing needs for the time allotment based on the conditions and day-to-day demands. 3) The pressure of timelines that are a part of research activity- to submit periodic reports/ grant proposals/ publications, etc.
What is a perfect balance?
By definition, a perfect balance should give consistent happiness to the clinician. It is achieved when the balance between clinical and research work, one desires is what one gets. But as mentioned above, this central point of balance is a shifting goal post and hence there can never be a perfect balance.
On paper, a 50-50 division of time between clinical and research work should be an ideal combination to have for a clinician-researcher. The clinical work will keep one in touch with clinical medicine which is important to guide the direction of research, but the 50% division should give adequate time for research. However as mentioned earlier the need for research time would vary from clinician to clinician depending on the type and extent of research that they are involved in. Hence there can be no standard prescription – a one size that fits all.
Realistically, clinician-researchers should consider themselves very lucky if they get a 60-40 distribution of their time between clinical work and research.
What are the compulsions that produce a mismatch between the ratio (between time for clinical work Vs research work) one desires, and what one gets?
1. Need to generate income: Research in most situations does not generate income. If one is self-employed, the stress on generating income is higher- leaving little time for research.
2. The priorities of the employer: The ideal position for a research-oriented clinician would be a university position that protects his/her research time. At the other extreme, most commercial hospitals would frown upon any time spent on anything other than patient care.
Fortunately, there are several private but science-oriented institutions that encourage research. But often these institutions are caught in a dilemma of promoting research Vs sustenance. It is in these horns of a dilemma that the clinician-scientist gets caught- causing a mismatch between what he/she desires and gets.
What is the solution?
Like most things in life, one has to compromise between what one desires and what one gets. The clinician should learn to maximize the utilization of the time available towards research. Clinical time is usually well utilised in view of well-structured fixing of appointments at regular intervals. In contrast, it is very easy to spend the research time without much outcome due to poor planning and thus feel miserable at end of the day.
What can major institutions do to promote quality research?
1) Allot a percentage of revenue expenditure towards research.
2) Identifying potential researchers among the clinicians.
3) Allotting time for research based on research output and not seniority.
4) yearly or 2 yearly review of research output.
5) Structured objective way of assessing research output eg: a) number and type of grants received b) Number of clinical trials /collaborative research studies/ prospective studies involved in or completed d) number of research related publications (publishing case reports cannot be considered as research output). Quantity and quality needs to be assessed for all the parameters.
6)Developing a sort of sliding scale that titrates the research time Vs clinical time based on clinician’s aptitude and performance.
Conclusion:
Balancing clinical work with research would need to be considered from the perspective of the clinician as well as the employer. While the clinician should maximise the utilisation of research time, the employer should be able to quantify research output and appropriately adjust the research time allotment. A clinician scientist by definition has to be involved in significant clinical work and cannot expect unfettered research time.