In Reply

We would like to thank Drs. Kamdar and de Gialluly for their thoughtful comments concerning our editorial.¹  It is heartening to hear from two members of our newest generation. They note “that extinct species are the ones that did not adapt to the stress and threats of their changing environment.” They are exactly correct—although we hope that one of the messages in our editorial was that we—as a profession— MUST ADAPT if we are to survive. We would argue that the program described by Sakai et al.²  is, in fact, one department’s effort to do just that.

They then go on to succinctly spell out some of the challenges that face new entrants to academic medicine: reduced National Institutes of Health dollars, bureaucratic obstacles, shrinking clinical revenues (which make it difficult for departments to provide the “startup” funds for young investigators), enormous time pressures (which are a direct consequence of falling clinical revenue vs. the cost of delivering care), and perhaps a changing vision of the value (and enjoyment) that comes with an academic career. Yet, in parallel, medical schools are coming to the realization that nontraditional pathways are important and promotion criteria are changing. In addition, there are multiple new journals, for example, HealthCare: The Journal of Delivery Science and Innovation, and other media that allow dissemination of these new ideas and can also lead to advancement of the field in addition to personal advancement.

Drs. Kamdar and de Giallully are entirely correct that future success at recruiting new academic physicians depends on our profession refocusing its efforts toward true innovation, rather than training residents and young faculty to do “more of the same things we did the same way we did it” (our words, not theirs).³  If we look back over the past 50 yr, there were true innovators who would also be considered some of the great researchers in our field, for example, John Severinghaus. However, innovation for innovation’s sake does not necessarily lead to our true goal of the triple aim of medicine: improved health care, better health, and affordable costs. The examples of Facebook, Google, and YouTube do not necessarily achieve those goals. These innovative and disruptive new technologies are the results of great creativity, but they are just modern sophisticated tools, not scientific results. In fact, the dissemination of bad information via these media or a new successful app could even harm the very patients we hope to help. It is only through testing and analyzing the results of the test can we achieve any of the aims of health care through innovative processes. That is scholarship and should lead to advancement.

The problem, of course, is that the same forces that oppose the development of a “traditional” research career get in the way of efforts at true innovation. Traditional research and 21st century innovation require time, money, and training. We do not know an easy solution to creating any of these—but programs similar to that described by Sakai—which can be implemented in a near-infinite number of variations if departments are sufficiently motivated—will still be central to our future success. It does not matter to us whether the product of such programs are “traditional” (papers, grants, etc.) or are new inventions, new ideas, new concepts, etc. To be incubators for such innovation, departments must seek out methods to expose new trainees to creativity—and the example the authors give of the program at Stanford is a good one. Given our goals in medicine, the key will be determining whether these new programs actually improve health and healthcare including the costs of delivering the services.

On the basis of our experience, there seems to be a misunderstanding among many younger individuals about what is really meant by research. Research is simply the process by which we identify a problem, ask a question, and then figure out how to answer that question. Humans are born researchers. The first time an infant reaches out his hand to touch a shiny object hanging over his crib, or sticks a strange item into his mouth (to the dismay of parents), he is doing research. “What is that thing; I think I’ll find out.” What is less clear is why this innate curiosity seems to disappear from many individuals by the time they leave medical school. Successful research or innovation at any level, on any subject, for any reason, requires curiosity. And most importantly, it requires hard work—work that can never be confined to the proverbial 40-h week. Insatiable curiosity is what drives that work; the founders of new companies (including Facebook) devote thousands of hours to their development. They do not do it primarily for money—they do it because of a burning desire to “answer a question” or solve a problem or to create something new.

What is missing from our profession today? Maybe too many academic departments—and perhaps medical schools—are lead by individuals who are too closely wedded to past models of success, who do not recognize the winds of change, or have no experience with research or the creative process.⁴  And part of the problem lies with some members of the younger generation. Too many shun even the concept of “research” (in even its broadest definition, including innovation, invention as well as determining its success). It is so much easier to go to work each day, do something fun (and doing anesthesia is great fun!), and get paid a lot of money. The solution can only come through departments that are willing to fight for support and guidance needed (like the University of Pittsburg) combined with motivated young people. It is also important that we train these innovative individuals in the methods by which we can determine whether we are achieving our stated goals.

We sincerely look forward to following the careers of Drs. Kamdar and de Giallully. If they are willing to put their thoughts into practice, they have very bright future.