As we emerge from the COVID-19 pandemic, it has never been more obvious that clinical research is an essential service to the public.
But worldwide, there are concerns that clinician researchers are a dying breed. This “endangered species”, capable of leading clinical care alongside a principal role in research, would be sorely missed in Australia. Clinician researchers here have led the world in defining treatable causes of disease, developing new therapies and vaccines, preventing disability and providing accurate quantitative advice to governments challenged by health emergencies.
So, is Australia doing enough to support trainees who hope to follow in the footsteps of leaders in these clinical research domains, such as Barry Marshall, Ian Frazer, Fiona Stanley and Jodie McVernon?
As research-minded doctors hailing from the UK, we think the answer to that question is “not enough, yet”. Twenty years ago, it seemed that UK clinician researchers were headed for extinction. By contrast with mainstream clinical medicine, there was no clear career track to attract young doctors into clinical research. UK Governments recognised the threat and supported drastic remedial action.
In 2005, we helped Mark Walport, at the time the Director of the Wellcome Trust, design and sustainably implement an integrated academic training track for doctors aspiring to be specialists or generalists. Crucially, a PhD and related postdoctoral work is typically completed during postgraduate clinical training rather than at medical school, thus increasing the chances that PhD training feeds through rapidly to provide the trainee with an up-to-date and clinically relevant research program as independence is achieved.
Integration of research training with clinical training is seen as a pragmatic preparation for life as a clinician researcher. The scheme provides competitive pre-doctoral, doctoral and postdoctoral research career development opportunities carefully aligned to every stage of postgraduate clinical training “from cradle to consultancy”. Importantly, particularly for doctors with family responsibilities, broad pay parity with contemporaries in mainstream training is ensured.
Within 10 years of the scheme starting, the number of clinician researchers across the UK was rising, not falling, and there was an unequivocal increase in the quantity, quality and impact of UK medical research.
Although at least 63% of Australian medical graduates are interested in research as part of their future medical career, the number of medically qualified researchers appears to be in decline in Australia. This is at a time when medical research funding in Australia has ramped up thanks to the Medical Research Future Fund. In a submission to the Medical Workforce Reform Advisory Committee, the Group of Eight universities argue strongly that to ensure a sufficient future supply of clinician researchers, around 5% of medical graduates should be able to access an integrated clinician researcher training program similar to the one in the UK.
In hospital specialties, the track includes about 20–33% of time for pre-doctoral work as a clinical research registrar during the first 2 or 3 years after competitive entry to a vocational training program. Trainees on the track would then undertake a full-time PhD program for 3 years before returning to clinical training as a senior clinical research registrar with 50% of time available for postdoctoral research. The scheme can also be adapted to suit those training in general practice and as rural generalists. Trainees completing the track and “collecting College letters” would be fully trained for independent medical practice and competitive for postdoctoral research fellowships enabling transition to independentresearch leadership. To recruit and retain the most promising and diverse cadre of trainees, the scheme would find ways to offer broad pay parity with those in conventional training.
This is a great scheme to propose, but is it feasible in Australia’s non-unitary, multipayer health care system? Thanks to a pilot now in place at the Melbourne Academic Centre for Health (MACH), we can confidently answer “yes”.
MACH is a National Health and Medical Research Council-designated Advanced Health Research Translation Centre that brings a research-intensive medical university together with eight medical research institutes and 10 large health services providing comprehensive care to over 2.5 million Victorians. The joint aim is to promote translation of research to improve health care and strengthen the economy. The partners are ideally placed to deliver together a training track for aspiring clinician researchers.
MACH-Track is a program for research-minded vocational trainees keen to move to a program where they are never out of either clinical training or research career development. MACH welcomed its first five trainees in February 2021 and at least five more will be recruited each year.
MACH partners have redeployed existing resources to establish the Track which “commits to trainees who have a commitment from their specialty.” Successful trainees must have won a place in an accredited vocational training program (advanced training for physicians). The five pioneers for the inaugural intake (two women and three men) are trainees in endocrinology and nuclear medicine, general practice, haematology, radiation oncology, and respiratory medicine; trainees in a much wider range of specialties applied to what proved to be an intense competition. MACH-Track is summarised in Figure 1.
MACH-Track will seek to recreate the ethos developed among the well supported and mentored cohort of trainees assembled over the past 13 years in Scotland through the Edinburgh Clinical Academic Track. Around 75 trainees, with a 50:50 gender split are on the Edinburgh Track or have graduated; around 50% have had at least one substantial period of family leave. The majority remain research active, with over two-thirds of graduates working in universities alongside clinical practice.
Health service CEOs are supporting trainees by allowing them to spend 20% of paid time on pre-doctoral research during the Track’s first, pre-PhD clinical training year. Over this period, three introductory pre-doctoral “mini-projects” are provided by the medical research institutes and the university, with the trainee using this supervised experience to develop a PhD proposal during the year. The next 3 track years are devoted to a full-time PhD, with the university providing the core PhD scholarship. In an effort to move towards pay parity with full-time clinical training, the core stipend will be topped up to 175% of base value by the university department or medical research institute hosting the PhD. Income is boosted further during this period as the parent health service will offer 20% of time as a supernumerary paid registrar.
When the PhD is complete, the doctor returns to clinical training, with health services guaranteeing 20% of paid time for postdoctoral research in the university or medical research institute until clinical training requirements are completed. Royal and specialist Colleges have been supportive, encouraging training committees to deploy existing flexibility to enable trainees to adapt their existing vocational program to allow completion of the MACH-Track. An example is deferring one trainee’s essential rural attachment to the end of clinical training so as not to disrupt place-dependent research momentum.
Our discussion has focused so far on doctors-in-training. It is hoped that MACH-Track can be adapted to suit the needs of research-minded nurses, midwives and allied health professionals. Improvement of health care requires clinician researchers from all professional backgrounds.
To conclude, although MACH-Track does not provide every element of the proposed Group of Eight scheme for doctors, it does demonstrate that the fundamental aim of integrating clinical and research training is feasible in Australia. MACH-Track also emphasises that new funding may not be required for every element of the Group of Eight track; as all parties benefit, universities, medical research institutes and health services are prepared to contribute to training the clinical innovators of the future (albeit in small numbers initially in the case of the MACH-Track). We strongly encourage multilateral discussions to secure nationwide implementation of the Group of Eight scheme. If this can be achieved, the future seems bright for aspiring clinician researchers in Australia.
Professor Sir John Savill is Executive Director of the Melbourne Academic Centre for Health.
Professor Stuart Carney is Deputy Executive Dean and Medical Dean in the Faculty of Medicine at the University of Queensland.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
First published in MJA Insight+ 26 April 2021.