Hail the Clinician Investigator – The Great Integrator

Nine years ago, when I began my first term as Chair, I was handed the departmental review and asked to pay close attention to the recommendations made by the two external reviewers. One of the recommendations was to get rid of the Clinician Investigator (CI) position description…completely! Why? Because it was felt to be an impossible academic role – asking people with ~ 50% clinical loads to produce research comparable to Clinician Scientists (CS). Was that really what we were asking them to do? Well, actually, yes! Or at least indirectly. When CIs came to three-year review (CFAR) or senior promotion, they were directly compared with CS faculty, which seemed completely crazy at the time. So, I asked our CIs at the time if they wanted to be CSs – the answer was almost uniformly NO – these folks wanted the balance (maybe often imbalance) of clinical care and scholarship that the CI position description offered. So, as any decent clinical epidemiologist would do, I looked at the data – were our CIs doing “worse” academically than other position descriptions? The answer was NO again!  So in this issue of DoM Matters, I thought I would take the opportunity to relay what I have learned about the CI position description – what appears to be the best recipe for success – and to highlight some of the many incredible achievements of our CIs. They have bedazzled me! They are the personification of excellence in creative professional activity through research! 

Snapshot: DoM CIs in 2023

Currently, we have 910 full time clinical faculty members in our department – of these, almost a quarter - 22% - are CIs (same proportion as for CSs!). 42% of CIs are women, which is a little higher than for CSs (36%) and a little lower than for the remaining position descriptions (45-47%). Of our 207 CIs, 87 (42%) are Assistant Professors, 47 (23%) Associate Professors, and 72 (35%) Full Professors.  

About one-third of all senior promotions each year are of CIs, who are promoted almost exclusively based on a combination of Creative Professional Activities (CPA) and Research. Let me remind you that CPA is a broad term that refers to activities that do one or more of the following: contribute to the development of professional practices, e.g., clinical practice guidelines; promote exemplary professional practice, e.g., models of care innovations; and professional innovations, e.g., patient education videos. The median number of years between promotions (i.e., Assistant to Associate or Associate to Full Prof) for CIs is 8 years (inter-quartile range 6-10 years), which is on par with CS faculty (7 years [IQR 6-9]).

If recruitment into the CI position description is any indication of how it is perceived as a career choice, the picture is favourable. Of the 35-40 full-time clinical faculty members recruited to the department every year, about half are CTs, but the next highest group is CIs at ~9 per year.

How Does One Make the CI Position Description Work?

While there is not one recipe for successful execution of the CI academic position description, I have observed that tight integration of one’s clinical and scholarly activities really helps. In other words, scholarship is directly derived from patient care interactions, through multidisciplinary and multispecialty research collaborations. For example, they might have a clinical focus on disease X and establish international recognition over time as an expert in disease X. They might establish a clinical cohort of patients with disease X and conduct or collaborate on studies to enhance understanding about disease X (clinical phenotypes, prognosis, response to treatment, pathogenesis, mechanisms of treatment response). Given their expertise in the disease X field, they will be invited to speak at conferences, rounds and other venues. They may also be invited to participate or lead the development of guidelines for the management of disease X nationally or internationally. They might play an important advocacy role on behalf of patients with disease X in lobbying government for access to specific testing, screening, a new medication, etc, or through the development of tools to educate. Over time, the CI generates a lot of new knowledge about disease X – this knowledge has been disseminated in multiple ways to advance the diagnosis and treatment of disease X. And, importantly, the CIs own patients have benefitted from their physician’s curiosity and dedication – people with disease X all want to be seen by this physician in their clinic. Residents and fellows want to come to learn from this CI – the CI often establishes a disease X fellowship to train others. And as they say, the rest is history!

CI Stories

Here are just a few CI “stories” taken from senior promotion over the past nine years. Apologies in advance for not being able to highlight all 99 CIs who were promoted over this time period, and for selecting only a snippet of information for each of the individuals highlighted below.

Marie Faughnan, Respirology, St. Michael’s Hospital - Unity Health, Promoted to Full Professor July 2018

Dr. Faughnan is a global leader in the field of hereditary hemorrhagic telangiectasia (HHT). She established the Toronto HHT Centre at St. Michael’s Hospital, which provides expert clinical care for these patients and serves as a rich resource for research in HHT. She led the first large prospective cohort study of HHT patients to increase understanding of the epidemiology of HHT. She quantified the rate of brain hemorrhage in HHT patients and demonstrated risk factors for hemorrhage. She has conducted translational research in collaboration with vascular biologists and genetic scientists, identifying novel targets and therapies for HHT, leading to early phase clinical trials in HHT. With the international patient advocacy group, CureHHT, Dr. Faughnan led the development of “OUR HHT Registry”, a comprehensive, multisystem patient registry, which has enabled creation of a multi-investigator research network across North America for the study of HHT outcomes. Finally, she led the development of the first and second International HHT Guidelines, which involved stakeholders from 15 countries and patients. She has given numerous invited international presentations and has been invited to consult on the establishment of HHT Clinics in Montreal, in the US and Ireland. In 2020, she received the Faculty Research Excellence Award from the Division of Respirology at University of Toronto. 

Mark Boulos, Neurology, Sunnybrook, Promoted to Associate Professor July 2023

Dr. Boulos has established a national reputation in the domain of sleep neurology with a focus in two areas: utilization of ambulatory equipment for detection of sleep disorders; and sleep disorders after cerebrovascular disease. His subspecialty clinics in sleep neurology are popular among trainees and have attracted research trainees from across Canada and the world. His “SLEAP SMART” trial compared the diagnostic utility of home sleep apnea testing with laboratory polysomnography in patients with stroke and transient ischemic attack (TIA). The study found ambulatory sleep assessments to be feasible, efficient, and cost-effective. This work was presented at multiple international conferences, resulted in several high impact publications, and an invitation to participate in an international committee of the American Academy of Neurology to produce evidence-based guidelines on the use of ambulatory sleep equipment for the detection of sleep disorders in home settings. Furthermore, he led preparation of a comprehensive meta-analysis of normal adult polysomnography parameters, which was published in The Lancet Respiratory Medicine; the accompanying website (psgnorms.com) has been accessed more than 12,500 times by sleep clinicians and researchers around the world. In 2020, he received the Wayne A. Hening Sleep Medicine Investigator Award from the American Academy of Neurology in recognition of outstanding achievements in sleep science research.

Alun Ackery, Emergency Medicine, St. Michael’s Hospital - Unity Health,  Promoted to Associate Professor July 2021

Dr. Ackery has applied innovative technologies to enhance patient and health provider experiences in the emergency department (ED). Among his many accomplishments, he has produced educational materials for physicians, including a narrated White Board Video (nWBV) for community ED physicians on the management of trauma patients. This work received national and international attention and led to an invitation by emergencymedicinecases.com, an internationally recognized emergency medicine podcast site, to produce a podcast. This, in turn, resulted in national and international speaking invitations and election to the Board of the Trauma Association of Canada (TAC), where he helped develop best practice trauma guidelines. In 2018, he was senior author on a CMAJ publication entitled “Is there a doctor on board?” Practical recommendations for managing in-flight medical emergencies. This work has been highly cited and received considerable media interest. To complement the article, Dr. Ackery led the production of a YouTube video for physicians called in flight to assist an ill passenger; this video has received more than 24,000 views.

Lianne Singer, Respirology, Toronto General - University Health Network, Promoted to Full Professor July 2020

Dr. Singer’s academic focus is on improving access to, and outcomes from, solid organ transplantation, with a particular interest in lung transplantation. She has recruited and prospectively followed a cohort of over 1,000 patients with advanced lung disease and lung transplant to assess predictors of post-transplant health-related quality of life (HRQL). This research has resulted in numerous seminal observations, including that lung transplantation confers very large quality of life improvements across all age groups and all clinical indications. Study findings have resulted in several high impact publications, including in the American Journal of Respiratory and Critical Care Medicine, and invitations to give international plenaries and talks. Cohort sub studies have elucidated the HRQL benefit of re-transplantation, candidates’ ability to predict their own post-transplant HRQL, and the HRQL benefit of transplantation in patients with COPD who do not have a predicted survival benefit. She is currently leading a five-center sub-study of HRQL in lung transplantation as part of a US National Institutes of Health (NIH)-sponsored clinical research consortium. She has also utilized clinical cohort data to develop and validate a frailty index for lung transplant candidates, undertaken a number of initiatives to reduce barriers to accessing transplantation, including creation and evaluation of a lung transplant Telehealth program, which provides access to lung transplant consultation and post-transplant care for patients across Canada. In 2018, Dr. Singer received the Canadian Society of Transplantation’s Dr. Joel D. Cooper Award, in recognition of outstanding contribution to the field of lung transplantation in Canada.

Nadine Shehata, Hematology, Mount Sinai, Promoted to Professor July 2021

Dr. Shehata has established an international reputation as an expert in the field of transfusion medicine and maternal hematology. She co-led a seminal randomized clinical trial comparing a restrictive versus more liberal policy of red blood cell transfusion in cardiac surgery (New England Journal of Medicine in 2017 and 2018). The trial found that the restrictive policy was non-inferior to the liberal approach, which has changed clinical practice. She is actively engaged in clinical practice guideline development and dissemination, including serving as Chair of the International Collaboration for Guideline Development, Implementation and Evaluation for Transfusion Therapies. In addition to her work on best practice in transfusion medicine, Dr. Shehata has made major contributions to the management of hematologic disorders in pregnancy. With colleagues in Obstetrics and Gynecology, she established a multidisciplinary specialized clinic in Maternal Hematology. The program has excelled with respect to the quality of clinical care provided and as a venue for post-graduate training. All hematology and obstetric medicine residents at U of T spend time in this clinic. She established a unique two-year fellowship program to provide advanced training in Maternal Hematology to hematologists and obstetricians and developed a rotation in Maternal Fetal Transfusion Medicine for fellows in Transfusion Medicine. Both fellowship programs have attracted national and international trainees.

Summary

I hope the above examples have impressed you as they did me! Our CIs are truly masterful integrators of the three pillars of academic medicine, clinical care, teaching, and scholarship. I am delighted to see ongoing recruitment of faculty members into the CI role, and their progression through the academic ranks at the University of Toronto. Most importantly, I am grateful for their truly impressive contributions to pursuing and actively disseminating new knowledge to improve the lives of their patients. Thank you CIs!